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Erectile Dysfunction Questions

You and your symptoms

Are you 18 years old or above and a male?


Do you smoke or drink?


Do you have trouble achieving or maintaining your erection?


Do you take any medication for the heart ?


Do you or have you suffered from any heart problems stroke, angina or any other heart related problems ?


Are you taking any medication that has been prescribed by your Gp/Doctor or Hospital ?


Do you give consent for us to contact you GP if required? (we need this to process any order for medication)


Your Current Health

Have you ever suffered from any of the problems listed below?


• heart problems including angina, chest pain, heart failure, irregular heart beats, heart attack (myocardial infarction), left-ventricular outflow obstruction, cardiomyopathy or valvular heart disease (e.g.aortic stenosis)?
• 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?
• 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 (cancer of blood cells) or multiple myeloma (cancer of bone marrow)?
• Stomach ulcers (e.g. peptic/gastric ulcer)?
• Liver problems?

Are you currently taking any medicines such as nitrates or nitric oxide donors?


  • taken for chest pain/angina
  • Can be taken as a spray, tablet or patch.
  • Include glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate

Are you taking any of the following medications?


  • Any treatment for erectile dysfunction apart from Viagra (sildenafil) , Levitra (vardenafil) or Cialis (tadalafil), Spedra (avanafil)
  • Medicinal nitrates such as glycyryl trinitrate, isosorbide mononitrate or isosorbide dinitrate (including oral, transdermal and sublingual)
  • Recreational drugs prohibited by law (Class A,B or C)
  • Recreational nitrates such as amyl nitrate also known as "poppers"
  • Alpha blockers (used to treat high blood pressure or urinary symptoms associated with benign prostatic hyperplasia, and including doxazocin, prazocin terazocin & indoramin)
  • Medicines to treat high blood pressure.
  • Warfarin - used to to prevent heart attacks, strokes, and blood clots
  • Anti-virals including (Atazanavir, etravirine, fosamprenavir, indinavir, nelfinavir,ritonavir, saquinavir)
  • Nicorandil
  • Anti-fungal medication such as Ketoconazole or itraconazole
  • Quinidine/procainamide/amiodarone
  • Theophylline
  • Erythromycin/clarithromycin/cimetidine
  • phenobarbital, phenytoin and carbamazepine (anticonvulsant medicines).

Is your blood pressure currently more than 160/90 or are you currently receiving treatment for high blood pressure?


  • If you do not know your blood pressure you can go to your local pharmacy or local GP to have your blood pressure measured.

Is your blood pressure currently below 90/50? (low blood pressure)


  • If you do not know your blood pressure you can go to your local pharmacy or local GP to have your blood pressure measured.

Has your local GP advised you to avoid strenuous exercise?


Would you find it difficult to walk a fast pace for 5 minutes?


Are you currently suffering from depression and not told your doctor yet?


Do you have an allergy to Viagra (sildenafil), Spedra (avanafil) Levitra (vardenafil), or Cialis (tadalafil) or have you experienced any negative reactions to any erectile dysfunction medication previously?


Agreement

Do you agree to the following statements?


  • You must read the patient information leaflet supplied with your medication
  • You must 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.
  • The treatment is solely for your own use only.
  • You have answered all the questions in this short medical assessment accurately and truthfully to the best of your knowledge. You understand our doctor take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
all of our tests and treatments are price competative

You need to complete our short medical questionnaire so we can ensure the treatment you have selected is safe for you to use

all of our tests and treatments are price competative

Need Help?

If you need help with this medical questionnnaire call us on 07549286701

 
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Quality products

all of our tests and treatments are price competative

Affordable prices

all of our pharmacies and and treatments purchased are from well known and trusted UK pharmacies

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all of our tests and any other products purchased will be dispatched for a next day service

Express next day delivery

If you have any further questions about any of our products please feel free to contact us and we will do our best to help you.
Once you have your prescription we will be able to process your order through our trusted UK Pharmacy.