About your condition and treatment
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
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Are you aware of how high or low your blood pressure is?
This could be from an examination by your doctor, a certified medical practitioner or self-examination.
If you are aware of your blood pressure condition, do you check with your doctor regularly to ensure it is under control?
Are you on any of the following medication?
Antibiotics.
Antihistamines such as stemizole or terfenadine.
Cisapride for stomach discomfort.
Quinidine for circulatory problems.
Pimozide for schizophrenia.
What is your biological gender?
Please select your option
If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option
Are you currently receiving any treatment or using any medication?
Please provide more information of the medication being used if any.
If you have a history of using any ED medication, did you suffer any side effects?
If you did, kindly describe the effects
Has a cerified medical practitioner examined you with erectile dysfunction?
Do you require assistance?
Have you ever been told that you have high or low blood pressure?
This may have been by your GP or another healthcare professional, or by taking your own blood pressure on a home monitor.
If you have tried ED treatments before, did you get any side effects? If yes, please let us know what you expreienced
Do you have an allergy to Sildenafil, Tadalafil or Vardenafil
Have you been diagnosed with erectile dysfunction by a doctor?
Have you had a serious reaction to an ED medicine before?
If yes, please describe the product/reaction.
Do you have higher or lower than normal blood pressure?
If yes, please provide details
Do you have a medical history of the following:
Heart disease, heart attack, angina (chest pain during exertion), stroke, mini-stroke (transient ischaemic attack), sight loss due to poor circulation, inherited eye disease – retinitis pigmentosa, severe kidney or liver disease, deformity of the penis (e.g. Peryonie’s Disease), painful erections, sickle cell disease / leukaemia / multiple myeloma, bleeding conditions (e.g. haemophilia), stomach ulcers (e.g. gastric/peptic ulcer)
Do you have symptoms of depression and have not seen a GP?
If yes, please provide details
Do you have any recent or past medical history of note?
If yes, please provide details
Are you aware that erectile dysfunction can sometimes mask underlying medical conditions, so it is recommended that you agree to consult your doctor about this?
Do you take any current or repeat medicines?
If yes, please provide details
Please list all your current prescription medication including any medication you buy over the counter...
Please write below any further information which may be relevant e.g. medicines, conditions...
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The Agreement
Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.
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Have you been diagnosed with a blood disorder?
Do you have any eye problems? This includes:
Papilloedema and Retinal vascular lesions
Do you have any problems with your stomach or gut (intestine), such as an ulcer or bleeding?
Have you been advised to avoid strenuous exercise?
If yes, please provide the reason
Have you ever had a painful erection?
Have you been advised to avoid strenuous exercise?
If yes, please provide the reason
Is walking or running difficult for you?
Have you taken any ED treatments before?
Have you taken either Sildenafil, Tadalafil or Vardenafil
Do you consent to seek medical help right away if you have any of the following symptoms:
An erection lasting more than 4 hours. Vision is hazy. One or both eyes have a sudden decline or loss of vision. Pain in the chest.
Have you tried any erectile dysfunction medication before?
You can select one or more options
Do you have difficulty in getting or maintaining an erection?
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.
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