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General

Assessment

Delivery

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Erectile Dysfunction

Please complete your confidential clinical assessment. Evaluated by GMC & GPhC registered healthcare professionals.

About You

The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.

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Are you registered with a GP practice in the UK? *

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you? *

(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

Do you believe you have the capacity to make decisions about your own healthcare? *

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

Are you male and aged between 18-75? *

Do you smoke or drink? *

Symptoms

Please answer the following medical questions to help us assess your suitability for treatment.

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Do you have trouble achieving or maintaining your erection? *

Health

Final questions about your treatment preferences and expectations.

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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.

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.

Have you been advised to avoid strenuous exercise? *

Do you get chest pain or shortness of breath walking short distances, or up a flight of stairs? *

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

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? *

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), transient ischaemic attack, 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 or myeloma (blood cancer)
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

Medication

Final questions about your treatment preferences and expectations.

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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

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)
edicinal nitrates such as glycyryl trinitrate, isosorbide mononitrate or isosorbide dinitrate (including oral, transdermal and sublingual)
ecreational drugs prohibited by law (Class A,B or C)
ecreational nitrates such as amyl nitrate also known as “poppers”
lpha blockers (used to treat high blood pressure or urinary symptoms associated with benign prostatic hyperplasia, and including tamsulosin, alfuzosin, doxazosin, prazosin terazosin & indoramin)
edicines to treat high blood pressure.
arfarin – used to to prevent heart attacks, strokes, and blood clots
nti-virals including (Atazanavir, etravirine, fosamprenavir, indinavir, nelfinavir, ritonavir, saquinavir, tipranavir)
icorandil
nti-fungal medication such as fluconazole or Ketoconazole or itraconazole
uinidine/procainamide/amiodarone
heophylline
rythromycin/clarithromycin/cimetidine
henobarbital, phenytoin and carbamazepine (anticonvulsant medicines).

Agreement

Final questions about your treatment preferences and expectations.

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Do you agree to the following? *

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
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.
I consent to being contacted by telephone or email should the doctor or pharmacist require further information to assess my order.
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 are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

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Erectile Dysfunction

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