Your Health
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.
What is your gender?
Please provide more detail.
Do you need help completing this questionnaire?
Please contact us on 020 7157 9759 or email [email protected] and we can assist you.
Do you believe that you have the capacity to make decisions about your own healthcare?
Sorry we can't offer you this treatment, please contact your GP.
Have you been diagnosed with any medical conditions?
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you suffer from any allergies?
Please provide details including which allergies and what symptoms you experience.
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Are you currently prescribed any GTN spray, tablets, patch, gel or cream or take nicorandil or any nitrate tablets (usually prescribed for heart conditions)?
Please provide more information
Do you drink or smoke?
Please be aware that alcoholic drinks and/or smoking can cause erection difficulties. We offer smoking cessation services through our website.
Do you persistently have trouble achieving or maintaining an erection when sexually aroused?
Please provide more details
Has your GP ever advised you that you are not fit enough for any physical or sexual activity?
Do you suffer from any issues with your heart, liver,kidneys or have diabetes?
Have you had a heart attack or stroke in the last 6 months?
Do you get breathless or suffer from chest pain with light activity such as going up two flights of stair or walking at a fast pace for five minutes?
Do you suffer from low blood pressure (below 90/50) or experience faints or collapsing because of it?
Do you suffer from high blood pressure (higher than 160/90) or are you currently being treated for high blood pressure?
Do you have any conditions affecting the shape of your penis?
Have you ever experienced an erection lasting longer than 4 hours?
Do you have any issues affecting your heart rhythm?
Do you suffer from any eye conditions such as non-arteric ischaemic optic neuropathy, retinal problems or retinitis pigmentosa?
Do you suffer from stomach/duodenal ulcers or blood conditions such as sickle cell, haemophilia or bleeding disorders?
Have you ever had an allergic reaction to any erectile dysfunction medicine?
Do you suffer from depression for which you have not seen a GP?
Do you agree to the following:
Consent
Would you like us to notify your GP of the treatment you chose to order today?
Please provide details.
It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.
If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.
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