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Medical Assessment

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About You
Are you male and aged between 18-75?
We are unable to supply you with medication for erectile dysfunction. Please consult your GP.
Please complete this question.
Do you smoke or drink?
You are eligible for treatment, however, be aware alcoholic drinks and/or smoking can make erection difficulties worse. Consult your GP for information on giving up smoking.
Please complete this question.
Have you taken Viagra (sildenafil), Levitra (vardenafil), Nipatra, Spedra or Cialis (tadalafil) at least 4 times previously without any side effects?
As you have not previously taken any erectile dysfunction medication, we will not be able to supply you with a high strength treatment as you must try a standard strength first.
Please complete this question.
Your Symptoms
Do you have trouble achieving or maintaining your erection?
It does not appear that you have erectile dysfunction. We are unable to supply you with treatment. Please consult your doctor for more information.
Please complete this question.
Your Health
Do you have any allergy to Viagra (sildenafil), Levitra (vardenafil), Spedra (avanafil) or Cialis (tadalafil) or have you experienced any adverse reaction to any erectile dysfunction medication previously?
We are unable to supply you with treatment. Please consult your doctor for more information.
Please complete this question.
Do you have high blood pressure (above 160/90), or are you currently on treatment for high blood pressure?
  • If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.
We are unable to supply you with treatment if you have high blood pressure. Please consult your GP for more information.
Please complete this question.
Do you have low blood pressure (below 90/50)?
  • If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.
We are unable to supply you with treatment if you have low blood pressure. Please consult your GP for more information.
Please complete this question.
Do you suffer from depression for which you have not seen a GP?
We are unable to supply you with treatment at this time. Please consult your GP.
Please complete this question.
Have you been advised to avoid strenuous exercise?
We are unable to supply you with treatment. Please consult your GP for more information.
Please complete this question.
Have you ever suffered from any of the problems listed below?
  • Any heart problems including angina, chest pain, heart failure, irregular heart beats, heart attack (myocardial infarction), left-ventricular outflow obstruction, cardiomyopathy or valvular heart disease (e.g.aortic stenosis).
  • Stroke
  • Sight loss due to poor circulation
  • Sight loss because of non-arteritic anterior ischemic optic neuropathy (NAION)
  • Blood problems such as haemophilia, sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood cells)
  • Stomach ulcers (e.g. peptic/gastric ulcer)
  • Liver problems
  • Kidney problems
  • An erection that lasted more than 4 hours
  • Any physical condition affecting the shape of the penis (e.g. angulation, Peyronie’s disease and cavernosal fibrosis)
  • Inherited eye disease - retinitis pigmentosa
  • Multiple myeloma (cancer of the bone marrow)
  • Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption
  • Any serious medical condition which may require immediate hospitalisation
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
Would you have any difficulty walking at a fast pace for 5 minutes?
We are unable to supply you with treatment at this time. Please consult your GP.
Please complete this question.
Your Medication
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
Are you taking any of the following medications?
  • Any treatment for erectile dysfunction apart from Viagra (sildenafil) , Levitra (vardenafil) or Cialis (tadalafil), Spedra (avanafil)
  • Medicinal nitrates such as glycyryl trinitrate, isosorbide mononitrate or isosorbide dinitrate (including oral, transdermal and sublingual)
  • Recreational drugs prohibited by law (Class A,B or C)
  • Recreational nitrates such as amyl nitrate also known as "poppers"
  • Alpha blockers (used to treat high blood pressure or urinary symptoms associated with benign prostatic hyperplasia, and including tamsulosin, doxazocin, prazocin terazocin & indoramin)
  • Medicines to treat high blood pressure.
  • Warfarin - used to to prevent heart attacks, strokes, and blood clots
  • Anti-virals including (Atazanavir, etravirine, fosamprenavir, indinavir, nelfinavir, ritonavir, saquinavir)
  • Nicorandil
  • Anti-fungal medication such as Ketoconazole or itraconazole
  • Quinidine/procainamide/amiodarone
  • Theophylline
  • Erythromycin/clarithromycin/cimetidine
  • phenobarbital, phenytoin and carbamazepine (anticonvulsant medicines).
  • Riociguat
  • Rifampicin
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
Are you taking any medicines known as nitrates (often taken for chest pain/angina) or nitric oxide donors ('poppers')?
  • Often taken for chest pain/angina
  • Can be administered as a spray, tablet or patch.
  • Include glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate
We do not advise any recreational drug use with PDE 5 inhibitors, but especially nitric oxide donors such as ‘poppers’ which may lead to a dangerous fall in your blood pressure. We are unable to supply you with treatment. Please consult your doctor for more information.
Please complete this question.
Agreement
I agree that in the rare event I obtain a prolonged erection of more than 4 hours, I will seek immediate medical assistance.
You must agree to this before continuing. If you need assistance contact customer support.
Please complete this question.
Do you agree to the following?
  • You will read the patient information leaflet supplied with your medication
  • You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
  • The treatment is solely for your own use
  • You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
  • You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber.
You must agree to this before continuing. If you need assistance contact customer support.
Please complete this question.
Complete our 2 minute questionnaire
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Ana Carolina Osorio De Faria Goncalves
To find a treatment suitable for you, we just need you to answer a few questions.
Ana Carolina Goncalves
Superintendent Pharmacist
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Need help?

If you need help with this medical assessment, contact our helpline:

0207 112 9014

or email us:

help@pharmica.co.uk
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