Generic Consultation – Erectile Dysfunction

1. About your Health

To help us understand that this treatment is the right option for you, please answer the following questions.

Please state your gender

This refers to your biological gender

Male

Female

What is your date of birth?

Use the calendar to select your date of birth.

Please add your height (in cms)

Your height is important for the prescribers decision.

Please add your current weight (in kgs)

Please make sure to add your current weight. This may affect the prescriber's decision.

Do you have any recent or past medical history of note?

If so, please provide more information

Yes

Do you suffer from any allergies?

If so, please provide more information

Yes

Do you currently take any medication whatsoever?

Please list all your current prescription medication including any medication you buy over the counter.

Yes

Is there a history of medical disorder's within your family?

If so, please provide more information

Yes

Are there any other health/medical details you feel we should know?

If so, please provide more information

Yes

2. About your Condition

To help us understand that this treatment is the right option for you, please answer the following questions.

Is this a repeat prescription?

Yes

Do you smoke or drink?

Please note: You are eligible for treatment if you smoke or drink, however, be aware alcoholic drinks and/or smoking can make erection difficulties worse. Consult your GP for information on giving up smoking.

Yes

Have you taken Viagra (sildenafil), Levitra (vardenafil), Nipatra, Spedra or Cialis (tadalafil) at least 4 times previously without any side effects?

Yes

Do you have trouble achieving or maintaining your erection?

Yes

Do you have high blood pressure (above 160/90), or are you currently on treatment for high blood pressure?

Please Note: If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Yes

Do you have low blood pressure (below 90/50)?

Please Note: If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Yes

Have you been advised to avoid strenuous exercise?

Yes

Would you have any difficulty walking at a fast pace for 5 minutes?

Yes

Do you suffer from depression for which you have not seen a GP?

Yes

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?

Yes

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

Yes

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

Yes

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 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

Yes

Do you understand that erectile dysfunction can be associated with a number of contributing conditions eg hypertension, diabetes mellitus, high cholesterol or cardiovascular disease and you should consult your doctor within 6 months of starting treatment for a clinical review?

Yes

In the rare event I obtain a prolonged erection of more than 4 hours or experience any sudden visual impairment, I agree that I will seek immediate medical assistance.

Yes

Is there anything else which you feel we should know about prior to you taking this medication?

Yes

3. The Agreement and Consent

Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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.

Yes

I agree to the Terms and Conditions and I confirm that I am over 18.
Terms and Conditions

Yes

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