Erectile Dysfunction Consultation

Are you Male and aged 18 years and older? *

Yes No

Do you find it difficult to get or maintain an erection satisfactory for sexual performance? *

Yes No

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

Yes No

Please provide more details

Have you ever had an allergic reaction to erectile dysfunction medication? Or have any other allergies we should be aware of? *

Yes No

Please provide more details on all allergies you have

Do you have or are you under a doctor's care for any of the following:

A heart operation, heart attack or stroke within the last 6 months or have a history of a stroke?
Low blood pressure (below 90/50) or uncontrolled high blood pressure (above 160/90)
Unstable angina (chest pain), irregular heart beat or palpitations (arrhythmia)
A problem with one of the valves in your heart (valvular heart disease)
A problem where the 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

*

Yes No

Please provide more details

Are you currently taking or have recently finished taking (in the last month) any medication, whether prescribed or non-prescribed including over-the-counter, herbal, or recreational drugs? *

Yes No

Please provide an update list of all medications whether prescribed or non-prescribed including over-the-counter, herbal, or recreational drugs that you are taking or have recently stopped taking

Do you or have you ever suffered from any of the following?

Bleeding issues (e.g. haemophilia)
Active stomach ulcer
Sickle cell anaemia or any other blood conditions
Multiple myeloma or leukaemia?
Previously diagnosed liver disease (including cirrhosis of the liver) or severe kidney impairment?
Galactose intolerance, Lapp Lactase deficiency, or glucose-galactose malabsorption
Vision loss due to non-arteritic anterior ischemic optic neuropathy (NAION), poor circulation, or eye conditions such as retinitis pigmentosa
Any physical condition that affects the shape of the penis such as Peyronie's disease, angulation and cavernosal fibrosis
Difficulty breathing (such as being 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?

*

Yes No

Please provide more details

Do you have diabetes, high blood pressure, high cholesterol, prostate problems or suffer from any mental health conditions? *

Yes No

Please provide more details

Do you smoke and/or drink alcohol? *

Yes No

Are you overweight? *

Yes No

Is there any other medical or non-medical information we should be aware of? *

Yes No

Please provide more details

Would you like us to inform your GP of any treatment you receive from us? *

We can still prescribe this medication to you if you select No, however, we do advise you to inform your GP of any treatment you receive from us to make sure your health records are up to date

Yes No

Before you continue

Please read the following statements:

I confirm these questions have been answered truthfully and accurately. I understand that any incorrect information may be detrimental to my health
I confirm the medication is for my personal use only and I should inform my GP of any treatment I receive from Pharmacy
I confirm I will take the medication as prescribed or directed for its intended use and if I am not requesting the starting dose for that medication, I have taken the medication previously on that dose and without any side effects
I have read or will read the patient information leaflet and I will contact a medical professional if I have any questions or experience any side effects while taking the medication
I will stop taking the medication immediately if I experience any of the following serious side effects: Chest pains; an erection lasting longer than 4 hours; a sudden decrease or loss of vision; an allergic reaction; serious skin reactions or experience a seizure or fit
All information provided will be handled in the strictest confidence in line with GDPR regulations. I am happy for Pharmacy to collect and use the information I provide for the purposes of providing treatment for my medical condition
I am happy to be treated by the prescribers and health care professionals at Pharmacy and the final decision on whether to provide treatment will be with the prescriber and or pharmacist
I understand I should not take NITRATE medicines, including recreational drugs such as poppers or cocaine, with medications used to treat erectile dysfunction as this can be very dangerous
I understand I should not take grapefruit or grapefruit juice at the same time as taking erectile dysfunction medication as it may increase the risk of getting side effects
I understand I should have my blood pressure checked regularly as well as testing for diabetes, high cholesterol or hormone imbalances

I agree to all of the above statements