About your condition and treatment
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
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Are you aware of how high or low your blood pressure is?
This could be from an examination by your doctor, a certified medical practitioner or self-examination.
Are you experiencing any of the following health issues?
You've had a heart procedure, a stroke, or a heart attack in the last five years.
You have angina, aortic stenosis, heart failure, cardiomyopathy, high blood pressure that is uncontrolled (greater than 160/90), arrhythmia, or severe heart disease.
You have suffered low blood pressure, fainting, or feeling dizzy when you stand up after lying down in the past.
Diabetes (type I or type 2) or blood sugar levels that are abnormal.
Medical diseases that impact the eyes, such as glaucoma or degenerative eye disease, as well as a family history of these conditions.
Peyronie's disease - a deformity or angulation of the penis.
Sickle cell disease, leukaemia, or multiple myeloma are all examples of blood cancers.
A disease that causes bleeding
What is your biological gender?
Please select your option
Have you ever been told that you have high or low blood pressure?
This may have been by your GP or another healthcare professional, or by taking your own blood pressure on a home monitor.
Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.
If you have a history of using any ED medication, did you suffer any side effects?
If you did, kindly describe the effects
Have you been diagnosed with erectile dysfunction by a doctor?
Have you tried any erectile dysfunction medication before?
You can select one or more options
If you have tried ED treatments before, did you get any side effects? If yes, please let us know what you expreienced
Do you have an allergy to Sildenafil, Tadalafil or Vardenafil
Have you had a serious reaction to an ED medicine before?
If yes, please describe the product/reaction.
Have you been advised to avoid strenuous exercise?
If yes, please provide the reason
Is walking or running difficult for you?
Do you have symptoms of depression and have not seen a GP?
If yes, please provide details
Do you suffer from any allergies?
If you do, kindly explain them below
Do you have difficulty in getting or maintaining an erection?
Do you have any recent or past medical history of note?
If yes, please provide details
Are you aware that erectile dysfunction can sometimes mask underlying medical conditions, so it is recommended that you agree to consult your doctor about this?
Please list all your current prescription medication including any medication you buy over the counter...
Please write below any further information which may be relevant e.g. medicines, conditions...
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