Medical Assessment for Erectile Dysfunction (ED)

Patient Information

Are you 18-65 years old?

Patient Symptoms

Do you have trouble achieving or maintaining your erection?

Medical History

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

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

• Severe heart disease
• Low blood pressure (below 90/50)
• Stroke in the last 6 months
• Sight loss due to poor circulation
• Severe liver disease
• An erection that lasted more than 4 hours
• Any physical condition affecting the shape of the penis

Do you have any of the following?

• Blood disease (sickle cell anemia, leukemia, multiple myeloma, hemophilia)
• Stomach ulcer
• Severe kidney disease
• Deformity of the penis

Are you taking any of the following medications?

• Any treatment for erectile dysfunction apart from sildenafil (Viagra) , vardenafil (Levitra), tadalafil (Cialis), avanafil (Spedra)
• Medicinal nitrates for chest pain
• Recreational nitrates such as amyl nitrate also known as "poppers"
• Recreational drugs prohibited by law
• Riociguat (for pulmonary hypertension)
• Alpha blockers for hypertension or benign prostatic hyperplasia (tamsulosin, doxazocin, prazocin)
• Anti-HIV drugs (atazanavir, nelfinavir, ritonavir, saquinavir)
• Anti-fungal medications (ketoconazole)
• Antibiotics (erythromycin, rifampicin)

Do you agree that in the rare event that any of these happen,  you will seek immediate medical assistance?

• Erection that is painful or prolonged (more than 4 hours)
• Seizure
• Chest pain during or after sex
• Serious allergic reaction (rash, itching, swelling of face/lips/tongue, difficulty breathing)

Consent

Do you agree to the following?

• You will take the medicine as directed by your doctor or as indicated in the information leaflet supplied with the medication
• You will contact us and inform your doctor if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment
• You will regularly follow up with your doctor to monitor blood cholesterol and sugar levels and liver function
• The treatment is solely for your own use
• 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 understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber