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Q1: Are you male? Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q2: Are you under 18 years of age? Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q3: Are you a smoker and do you consume more than 2 cigarettes a day? Yes No

Q1: Are you having difficulty in getting and/or maintaining an erection satisfactory for sexual performance Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q2: Have you used any medication for erectile dysfunction before? Yes No Q1: Did it work Yes No
Q2: Did you experience any side effects? Yes No

Q3: Do you have any allergy to Sildenafil, tadalafil and vardenafil or any of its ingredients? Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q4: Are you allergic to any medicines or other substances, for example peanuts or soya? Yes No

Q1: Has your doctor advised that you are not fit enough for any physical and/or sexual activity? Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q2: 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? Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q3: Have you had a heart attack or stroke within the last 6 months? Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q4: Do you suffer from low blood pressure (i.e. less than 90/50mmHg), and/or are prone to faints or collapses? If you are unsure, check with your GP or local pharmacy. Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q5: Do you have high blood pressure (i.e. above 150/90mmHg)? If you are unsure, check with your GP or local pharmacy? Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q6: Do you have any other heart problems or are you under a doctor’s care for any of the following: 1. Low blood pressure or uncontrolled high blood pressure
2. Unstable angina (chest pain), irregular heart beat or palpitations (arrhythmia)
3. A problem with one of the valves in your heart (valvular heart disease)
4. A problem where the heart muscle becomes inflamed and does not work as well as it should (cardiomyopathy)
5. Heart problems causing blood flow issues (e.g. left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure
Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q7: Do you have Peyronie's disease, angulation or any other deformation of the penis? Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q8: Have ever had loss of vision because of damage to the optic nerve (such as non-arteritic anterior ischaemic optic neuropathy [NAION]) or have an inherited eye disease? Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q9: Do you have galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption? Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q10: Do you have previously diagnosed liver, kidney or urinary problems? Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q11: Do you currently suffer from diabetes or abnormal sugar levels? Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q12: Do you have any of the following health conditions: a) Sickle cell anaemia
b) Multiple myeloma
c) Leukaemia
d) Bleeding issues (e.g. haemophilia)
e) Active stomach ulcers
Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q13: Are you currently using any other medication, even if you’re not taking it regularly? Select from list below: Nicorandil
Nitrate medication such as Glyceryl Trinitrate (GTN), Isosorbide Mononitrate and Dinitrate. (including sprays, patches, gels or creams)
Existing erectile dysfunction treatment
Alpha-blockers: Alfuzosin, Doxazosin, Indoramin, Prazosin, Tamsulosin, Terazosin
Antibacterials: Rifampicin, Erythromycin, Clarithromycin, Telithromycin, Gatifloxacin
Antivirals: Atanzavir, Indinavir, Ritonavir, Saquinavir, Telaprevir, Fosamprenavir, Tipranavir, Nelfinavir, Aprinovir or Etravirine
Oral Antifungals: Ketoconazole, Itraconazole, Voriconazole, Fluconazole
Cobicistat
Disopyramide
Dapoxetine (Priligy)
Cimetidine
Bosentan
Riociguat
Please list any other prescription medicines you are taking
We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q14: Do you take any recreational drug such as Amyl Nitrate (poppers) or cocaine? Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

Q1: Please confirm that you are aware of the following: a. You should not take any combination of erectile dysfunction medications on the same day
b. You should only take the higher strength treatments (sildenafil/Viagra 100mg, tadalafil/Cialis 20mg, vardenafil/Levitra 20mg or Spedra 200mg) if you have used the intermediate strengths before on at least 4 occasions without any side effects.
c. You should avoid taking grapefruit juice or alcohol whilst using any erectile dysfunction treatment
d. Being overweight or smoking or drinking alcohol regularly can make erection problems worse. Therefore, it is important to lead a healthy lifestyle by losing weight, only drinking alcohol in moderation and quitting smoking. Please refer to our website for further healthy lifestyle support.
e. You are recommended to have regular blood tests for high cholesterol, blood sugar (diabetes) and hormone imbalances (such as thyroid, testosterone or prolactin), as these conditions may contribute to erection difficulties
f. You should seek immediate medical attention if you have a continuous erection for 2 hours or more.
Yes No We are unable to supply you with medication for erectile dysfunction. Please consult your GP.

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