Erectile dysfunction consultation

01Is this medication and/or treatment for you?

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02Please tell us who it is for, including their age.

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03Do you have difficulty in obtaining erections sufficient for penetration and/or maintaining erections during sex? This may be all the time or just occasionally.

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04Please give more details as to why you are ordering this product.

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05Have you experienced erectile dysfunction that you believe is related to anxiety or stress?

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06Please give more information to help our doctors choose the right treatment.

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07Do you have a condition where sexual intercourse is not advised (i.e. any severe heart disorders such as unstable angina or severe cardiac failure)?

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08Have you used any medication for erectile dysfunction before?

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09Please provide as much information as you can, including any treatments already tried.

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10Do you have a hereditary degenerative retinal disorder such as retinitis pigmentosa?

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11Do you suffer from Peyronie's disease or have any other physical abnormality of the penis?

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12Have you had a diagnosis for this from a doctor or specialist? Please give details.

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13Are you taking any HIV medication such as a protease inhibitor (e.g. Ritonavir or Saquinavir), Erythromycin, Ketoconazole or Itraconazole?

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14Please provide as much information as you can, including who prescribed them if applicable.

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15Are you taking amyl nitrate (poppers), Nicorandil, Isosorbide Mononitrate / Dinitrate tablets, or using a GTN spray for angina?

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16If ordering injectable medication (e.g. Caverject / Alprostadil), have you used this type of treatment before? (If not ordering, answer No.)

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17Please provide as much information as you can, including who prescribed it if applicable.

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18If ordering injectable medication, have you been trained to safely use this injection? (If not ordering, answer No.)

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19Please provide the name of the healthcare professional who gave you the training and the date it took place.

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20Do you take any medication or have any medical conditions?

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21Please list ALL of the medication you take and any medical conditions you have.

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22Are you allergic to any medication?

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23Please give as much information as you can.

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24Do you have any specific disabilities or special needs that we should be aware of to provide you with the best possible care?

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25Please give more details, including any specific measures we can take to help you order the correct treatment.

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26Do you have high or low blood pressure?

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27Please give more details, including your latest BP reading with a date.

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28Do you smoke any tobacco products or use a nicotine-containing vape?

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29Please give more details, e.g. 10 cigarettes per day.

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30Do you drink alcohol?

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31Please give more details, e.g. 20 units per week.

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32Do you have any liver or kidney problems?

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33Please give as much information as you can, including any recent blood test or kidney function results.

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34I understand that erectile dysfunction may be an early indicator of diabetes, raised blood pressure or cardiovascular problems.

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35I am over 18 and this is for my sole use. I understand this is a non-emergency online service. I confirm I have answered all questions accurately and understand the doctor will use this information to prescribe safely for me.

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36I consent to treatment, identity check and for the pharmacist to access and store relevant information from my NHS summary care record which may be needed to safely prescribe. I also agree to read the Patient Information Leaflet supplied with my medication.

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37By providing us with your details you confirm that you have read, understood and agreed to the legal terms, and you consent to the sharing of your data to use our service.

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