Erectile Dysfunction Consultation

Your complete and honest disclosure will enable our healthcare professionals to make informed decisions and provide you with the best possible care. Please provide accurate and detailed information when needed in the consultation questionnaire below.

Do you need help completing this questionnaire? Email us or Call us during our working hours (9am - 5pm / Monday - Friday)

Name *

First

Last

Phone

Email *

GDPR Agreement *

I consent to having this website store my submitted information so they can respond to my inquiry.

What is your gender *

Male
Female
Other

What is your date of birth? *

Have you been diagnosed with any medical conditions? *

Please provide more information. *

Please use a comma to separate each condition

Have you ever been diagnosed with a mental health illness? *

Please provide more information. *

Please use a comma to separate each condition

Do you suffer from any allergies? *

Please provide more information. *

Please use a comma to separate each allergy

Do you drink or smoke? *

ℹ️

You are eligible for treatment, however, be aware alcoholic drinks and/or smoking can make erection difficulties worse. Consult your GP for information on giving up smoking.

suffered, avoid you

Have you had any Erectile Dysfunction treatment before? *

Please state which medication you have had *

Please use a comma to separate each medication

Are you male and are you between 18-75 years of age? *

Do you currently have trouble achieving or maintaining an erection? *

How active are you per week? (insert number) *

Are you currently being treated for high blood pressure (above 160/90)? *

If unsure, your blood pressure can be measured at a pharmacy or GP surgery.

Do you currently have low blood pressure (below 90/50)? *

If unsure, your blood pressure can be measured at a pharmacy or GP surgery.

Do you have difficulty walking at a fast pace for 5 minutes or have you been told to avoid strenuous exercise? *

Do you currently, or have you ever suffered, from any medical conditions? *

Please provide more information *

Have you ever suffered from any of the medical conditions below; *

*Sight loss due to poor circulation or non-anterior ischemic optic neuropathy (NAION)
*Retinitis pigmentosa
*Inherited eye disease - retinitis pigmentosa
*Myeloma
*Galactose intolerance, Lactase deficiency or glucose-galactose malabsorption
*Haemophilia, sickle cell anaemia (an abnormality of red blood cells)
*Leukaemia
*Stomach ulcers
*Stroke
*Any heart problems including angina, chest pain, heart failure, irregular heartbeats, heart attack (myocardial infarction), left-ventricular outflow obstruction, cardiomyopathy or valvular heart disease (e.g. aortic stenosis).
*Liver problems/ Kidney problems
*An erection that lasted more than 4 hours
*Physical condition affecting the shape of the penis (e.g. angulation, Peyronie’s disease and cavernosal fibrosis)
*Any serious medical condition which may require immediate hospitalisation

Do you have any allergies or hypersensitivity to Viagra (sildenafil), Cialis (tadalafil), Levitra (vardenafil), or Spedra (avanafil)? Or have you experienced any reactions to erectile dysfunction medication in the past? *

Please provide more information *

Are you currently taking any prescription medication, over the counter, medication, recreational drugs or herbal medication? *

Are you taking any of the following medications; *

* Any treatment for erectile dysfunction apart from Viagra (sildenafil), Levitra (vardenafil), Cialis (tadalafil), or Spedra (avanafil)
* Alpha blockers such as tamsulosin, doxazocin, prazocin, terazocin & indoramin
* Medicines to treat High Blood Pressure
* Warfarin
* Ketoconazole or itraconazole
* Quinidine/procainamide/amiodarone
* Anti-virals including Atazanavir, etravirine, fosamprenavir, indinavir, nelfinavir, ritonavir, saquinavir
* Theophylline
* Erythromycin/clarithromycin/cimetidine
* Phenobarbital, phenytoin, and carbamazepine
* Nitrates such as glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate or Nicorandil
* Recreational nitrates eg. amyl nitrate / 'poppers'
* Recreational drugs prohibited by law (Class A, B, or C)
* Any other medication

Please specify any other medication *

Please confirm the below *

* I agree to ordering the lowest strength, if this is the first time I am taking this medication.
* I confirm I am over 18 years old.
* The medicine being requested is for my use only.
* I will read the patient information leaflet supplied with the medicine, specifically the side effects and dosages.
* I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.
* I have answered all the questions truthfully.
* I understand my request still needs to be reviewed and approved by the prescriber; until they approve, my request is not guaranteed at this stage.
* I confirm I have the capacity to make decisions about my own health.
* I agree to the The Pill Box terms and conditions.

❗

Please confirm the details provided are accurate and truthful. Your request cannot be reviewed until confirmation is received.

Would you like us to inform your doctor of the treatment you chose to order today? *

To continue, please provide your GP's surgery address below. *

Erectile Dysfunction Consultation Form

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