Do you believe you have the capacity to make decisions about your own healthcare?

Are you male aged between 18 - 64?

Does premature ejaculation cause you personal distress or inter-personal difficulty with your partner?

Do you suffer any pain whilst ejaculating, or do you have any difficulty or pain passing urine?

Do you have trouble achieving or maintaining your erection?

Do you have high blood pressure (above 160/90), or are you currently on treatment for high blood pressure?

• If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

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

• If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Have you been advised to avoid strenuous exercise?

Do you get chest pain or shortness of breath walking short distances, or up a flight of stairs?

Do you suffer from depression for which you have not seen a GP?

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

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

• Any heart problems including angina, chest pain, heart failure, irregular heart beats, heart attack (myocardial infarction), transient ischaemic attack, left-ventricular outflow obstruction, cardiomyopathy or valvular heart disease (e.g.aortic stenosis).
• Stroke
• Sight loss due to poor circulation
• Sight loss because of non-arteritic anterior ischemic optic neuropathy (NAION)
• Blood problems such as haemophilia, sickle cell anaemia (an abnormality of red blood cells), leukaemia or myeloma (blood cancer)
• Stomach ulcers (e.g. peptic/gastric ulcer)
• Liver problems
• Kidney problems
• An erection that lasted more than 4 hours
• Any physical condition affecting the shape of the penis (e.g. angulation, Peyronie’s disease and cavernosal fibrosis)
• Inherited eye disease - retinitis pigmentosa
• Multiple myeloma (cancer of the bone marrow)
• Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption
• Any serious medical condition which may require immediate hospitalisation

Are you taking any medicines known as nitrates (often taken for chest pain/angina) or nitric oxide donors ('poppers')?

• Often taken for chest pain/angina
• Can be administered as a spray, tablet or patch.
• Include glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate

Do you understand that if you experience any side effects of treatment such as changes in mood or any seizures, you must discontinue treatment immediately and seek urgent medical attention from a doctor?

Do you understand that if you feel light headed soon after standing, you should immediately lie down so your head is lower than the rest of your body or sit down with your head between your knees until the symptoms pass? You should also ensure you do not rise too quickly after prolonged lying or sitting and do not drive or operate machinery if you experience these symptoms.

Do you agree to the following?

• I confirm I am over 18 years old.
• The medicine ordered is for my sole use only.
• I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
• I consent to being contacted by telephone or email should the doctor or pharmacist require further information to assess my order.
• 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 are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.