Are you registered with a GP practice in the UK?

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you.)

Do you believe you have the capacity to make decisions about your own healthcare?

Do you have trouble achieving or maintaining your erection?

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

Have you been advised to avoid strenuous exercise or have any difficulty walking at a fast pace for 5 minutes?

Do you have high blood pressure (above 160/90), or are you currently on treatment for high blood pressure?
If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Do you have low blood pressure (below 90/50) or experience faints or collapsing because of it?
If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery

Do you smoke or drink alcohol?

Do you have any known allergies?

Is your Body Mass Index (BMI) above 30? Use this URL to find out:  https://www.nhs.uk/live-well/healthy-weight/bmi-calculator/

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

• Any 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).
• 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)
• Stomach ulcers (e.g. peptic/gastric ulcer)
• Liver problems
• 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

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Are you taking any medicines known as nitrates (often taken for chest pain/angina) or nitric oxide donors ('poppers')?

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

• I confirm I am over 18 years old.
• The medicine ordered is for my sole use only.
• I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
• You will 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.
• I consent to being contacted by telephone or email should the pharmacist require further information to assess my order.
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
• You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.