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Do you have difficulty getting an erection or maintaining an erection?

Yes

What is your biological sex? (at birth)

Have you ever previously used the erectile dysfunction medication you are ordering?

Yes

Are you taking any nitrate medications such as glyceryl trinitrate (GTN) spray, tablets, patches or ointment; isosorbide mononitrate; isosorbide dinitrate; nicorandil or recreational amyl nitrate ('poppers')?

WARNING: There can be a fatal reaction between erectile dysfunction medication and these medications

Yes

Are you taking any of the following medications?

Riociguat

QT prolonging drugs (quinidine, procainamide, amiodarone and stoalol)

CYP3A4 inhibitors: (ritonavir, saquinavir, indinavir, atazanvir, itraconazole, ketoconazole, clarithromycin, erythromycin, cimetidine and grapefruit juice)

CYP3A4 inducers: (rifampicin, phenobarbital, phenytoin and carbamazepine)

Sacubitril/ Valsartan (brand Entresto)

None of the above

Are you taking medicines called Alpha-blockers which are normally used for blood pressure or prostate problems?

(e.g. alfuzosin, prazosin, doxazosin, tamsulosin)

Yes

Are you taking Finasteride or Dutasteride?

Yes

Apart from those already declared, do you take any other prescription, non-prescription or recreational medication?

Yes

Do you have any of the following conditions affecting your penis?

Anatomical deformation (e.g. angulation, curvature, cavernosal fibrosis, peyronies)

History of recurrent priapism or conditions which predispose to it (prolonged erection of the penis)

Sickle cell anaemia, multiple myeloma, leukaemia, thromobocythemia or polycythemia

Balanitis

Acute or chronic urethritis

Hypospadias

None of the above

Have you suffered from any of the following events in the last 6 months?

Confirm your blood pressure is between 90/50 and 170/100 mmHg before taking this medication.

You can have your blood pressure checked at your GP or local pharmacy.

Confirm

Have you been advised by a doctor to avoid sexual activity or strenuous exercise due to the health of your heart?

Yes

Do you have any of the following conditions?

Weakened liver function

Weakened kidney function

Active peptic ulceration

History of gastrointestinal disease, including erosive gastritis; gastrointestinal bleeding and gastric and/ or duodenal ulcer

None of the above

Do you have any of the following eye conditions?

Do you have any allergies or sensitivities?

Yes

Do any of the following statements concerning your overall health and lifestyle apply to you?

Overweight (Body Mass Index (BMI) above25)

Do not undertake at least 150 minutes of moderate intensity activity a weak or 75 minutes of vigorous intensity activity in a week

Smoker (including, vapes and e-cigarettes)

Regularly drink more than 14 units of alcohol per week

None of the above

Is there any other information you feel would be useful for our clinicians to know about?

Yes

Do you understand that you must NOT use more than one treatment for Erectile Dysfunction at any time?

Select Yes to confirm

Yes

The maximum single dose of Sildenafil/Viagra is 100mg. The maximum single dose of Tadalafil/Cialis is 20mg.

Select Yes to confirm

Yes

It is important to speak to your GP about your Erectile Dysfunction (ED). If you feel there is a psychological cause to your Erectile Dysfunction, which is typically characterised by the ability to have early morning and nocturnal erections but the inability to achieve or maintain an erection during a sexual encounter with a specific partner, you may find counselling beneficial. Please consider discussing this with your GP and seeking further support. If you are unable to achieve early morning or nocturnal erections, or unable to get an erection at all, then this may be a sign of an underlying health issue such as a cardiovascular (heart) issue, diabetes or hormone issue and we recommend you speak to your GP about the need for further investigations, testing and a general health check

Please tick to confirm you understand:

Please confirm that you agree to seek urgent medical attention if you experience any of the following symptoms:

. A continuous erection which persists for longer than 4 hours . Blurred vision . Sudden decrease or loss of vision in one or both eyes . Chest pain Select Yes to Confirm

Yes

Are you currently registered with a UK GP practice?

Yes

Assessment

Erectile Dysfunction Consultation

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