1. Have you read information about your symptoms on Patient.info?

Yes

No

2. Do you sometimes or always have difficulty getting and keeping an erection?

Yes

No

3. Have you had difficulties with erections for more than a year?

Yes

No

4. Are your erections sometimes fine?

• E.g. when waking in the morning, during masturbation or in some erotic situations

Yes

No

5. Is your blood pressure high (Over 160/90)

• You must have had a blood pressure check within the last year and know the result. Doctors, nurses and some pharmacist can check blood pressure. Answer 'Yes' if either figure is high, 160 or 90. A blood pressure measurement whilst taking blood pressure tablets qualifies.

Yes

No

Don't Know

6. Do you have low blood pressure?

• This means any of the following:
• Low blood pressure requiring investigation
• Low blood pressure requiring treatment
• Being prone to faint or feel light-headed for more than a few seconds when standing up quickly or standing for long periods

Yes

No

Don't Know

7. Are you over weight?

• Use this BMI (Body Mass Index) calculator and answer 'yes' if the result is over 30.

Yes

No

8. Do you smoke or drink more than 21 units of alcohol per week?

Yes

No

9. Have you been diagnosed with any of the following?

• Allergy or reaction to previous impotence treatments
• Heart disease including recent heart attack or angina (heart pain on exertion)
• History of stroke or mini stroke (transient ischaemic attack)
• History of vision problems due to poor circulation
• Family history of the degenerative eye disease, including retinitis peigmentosa (rare)
• Serious kidney/renal or liver disease
• Deformity or angulation of the penis (Peyronie?s disease)
• Sickle cell disease or leukaemia or multiple myeloma
• A bleeding disorder (such as Haemophilia)
• Active stomach ulcers (also known as peptic ulcer or gastric ulcer)

Yes

No

10. Are you taking any of the following?

• Existing ED treatment apart from Viagra/sildenafil, Cialis, Levitra or Spedra
• Nitrates for angina or heart failure, includes glyceryl trinitrate, isosorbide mononitrate, isosorbide dinitrate, GTN spray or gel, or nicorandil
• Ritonavir or Indinavir or medicine for HIV
• Ketoconazole or itraconazole or other anti-fungal medication
• The recreational drug amyl nitrate (Poppers)
• Alpha-blockers (sometimes used to treat high blood pressure or prostate enlargement) includes alfuzosin, doxazosin, indoramin, prazosin, tamsulosin, terazosin

Yes

No

11. Have you been advised to avoid vigorous exercise?

• E.g. severe heart failure or unstable angina

Yes

No

12. Are you aware, if you have a continuous erection for 4 hours or more. you should seek immediate medical advice?

• This is unlikely to happen and is rare. If it occurs you should seek medical advice straight away.

Yes

No

13. Are you aware you should not take any combination of Viagra/sildenafil, Cialis, Levitra or Spedra, or use Vitaros cream or any other ED treatment, at the same time?

• A break of up to 24 hours (36 hours for Levitra) should be left.

Yes

No

14. Are you aware that Erectile Dysfunction medication is available on the NHS, only for certain medical conditions? If you don?t suffer from these medical conditions, the doctor may need to issue you with a private prescription. This will be free of cost.

Yes

No

15. Do all of the following apply to you?

• I will read the patient information leaflet supplied with my medication.
• The medication is for my own use. (Partners, spouses etc must log out, complete their own consultation and register separately)

Yes

No