Erectile dysfunction

Are you male aged between 18-70 years old ?*

Are you transgender and transitioning, or have you transitioned from male to female? *

Has your doctor advised that you are not fit enough for any physical and/or sexual activity?*

Do you have difficulty getting or maintaining an erection?*

Over the last 6 months, when you had erections with sexual stimulation, how often were your erections hard enough for penetration?*

Over the last 6 months, during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?*

Over the last 6 months, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?*

Over the last 6 months, when you attempted sexual intercourse, how often was it satisfactory for you?*

How do you rate your confidence that you could get and keep an erection?*

Do you feel very breathless or experience chest pain with light or moderate physical activity, such as walking briskly for 20 minutes or climbing two flights of stairs?*

Have you had a heart attack or stroke within the last 6 months?*

Do you have any other heart problem or under a doctor\'s care for any of the following?*

• Low blood pressure (below 90/50) or high blood pressure (above 150/90), if you are unsure, check with your GP or local pharmacy.
• Unstable angina (chest pain), irregular heart beat or palpitation (arrhythmia).
• A problem with one of the valves of your heart (valvular heart disease)
• A problem where your heart muscle becomes inflamed and does not work as well as it should (cardiomyopathy)
• Heart problems causing blood flow issues (e.g. left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure.

Have you ever suffered from any of these conditions?*

• Peyronie’s disease or any other deformation of the penis
• Loss of vision because of damage to the optic nerve
• Galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption
• Been previously diagnosed with liver disease (including cirrhosis) or severe kidney impairment
• Sickle cell anaemia, multiple myeloma or leukemia
• Bleeding issues e.g. hemophilia or have active stomach ulcer
• Degenerative eye disease (such as retinitis pigmentosa), condition involving loss of vision due to damage to the optic nerve from insufficient blood supply known as non-arteritic ischemic optic neuropathy (NAION)

Do you have any allergies?*

Are you taking nitrates (nicorandil or other nitric oxide donors e.g. glyceryl trinitrate (GTN spray), isosorbide mononitrate or isosorbide dinitrate) for chest pain?*

Do you take any current or repeat medicines of the follow medication *

• Alpha-BlockersAlpha-Blockers – e.g. Doxazosin
• Anti-virals - mainly protease inhibitors. Atazanavir, etravirine, fosamprenavir, indinavir, nelfinavir, ritonavir, saquinavir.
• Nicorandil
• Riociguat
• Treatments for arrhythmias -e.g. quinidine, procainamide
• Imidazole antifungals - Ketoconazole, imidazole
• Macrolide antibiotics - Clarithromycin, erythromycin, telithromycin

Are you currently or have you previously been prescribed any medication for erectile dysfunction?*

Are you wanting to change your current medication for erectile dysfunction? *

Have you experienced any side effects or adverse reactions from previous use of medication for erectile dysfunction? *

Is the prescribed dose sufficient to achieve the desired improvement in erectile function?*

Are you aware you should not take any combination of erectile dysfunction medication at the same time?*

You understand if you have erection for 4 hours or more you should seek immediate medical attention.*

Can we share this information with your General practitioner? Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to contact your regular prescriber if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.*

To ensure your medication is prescribed safely, our clinical team may need to:*

• Access your medical records (including your Summary Care Record, where applicable)
• Invite you to take part in a follow-up phone or video consultation for further clarification

If you have previously initiated treatment elsewhere and are now requesting a step-up dose as your first order with our pharmacy. Please upload previous use evidence, which could be a prescription, dispensing label (found on packaging), receipt or dispatch confirmation and make sure the following is visible:*

• Order Date/ Prescription Date/ Dispatch Date
• Medication name and dosage
• Your name or email address
• Be from a regulated body

Please upload document *

Do you agree to the following?*

• You are aware that this medicine can lower your blood pressure, increasing the risk of falls
• You have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health
• You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable
• You will inform your doctor about any unusual side effects
• The treatment is solely for your own use
• You will read the patient information leaflet supplied with your medication
• You will not exceed the maximum daily dose of this medication
• You confirm you have the capacity to make decisions about your own health