Are you male and aged between 18-75?

Do you smoke or drink?

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?

Would you have any difficulty walking at a fast pace for 5 minutes?

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), 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 (cancer of blood cells)
• 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

Are you taking any of the following medications?

• Any treatment for erectile dysfunction apart from Viagra (sildenafil) , Levitra (vardenafil) or Cialis (tadalafil), Spedra (avanafil)
• Medicinal nitrates such as glycyryl trinitrate, isosorbide mononitrate or isosorbide dinitrate (including oral, transdermal and sublingual)
• Recreational drugs prohibited by law (Class A,B or C)
• Recreational nitrates such as amyl nitrate also known as "poppers"
• Alpha blockers (used to treat high blood pressure or urinary symptoms associated with benign prostatic hyperplasia, and including tamsulosin, doxazocin, prazocin terazocin & indoramin)
• Medicines to treat high blood pressure.
• Warfarin - used to to prevent heart attacks, strokes, and blood clots
• Anti-virals including (Atazanavir, etravirine, fosamprenavir, indinavir, nelfinavir, ritonavir, saquinavir)
• Nicorandil
• Anti-fungal medication such as Ketoconazole or itraconazole
• Quinidine/procainamide/amiodarone
• Theophylline
• Erythromycin/clarithromycin/cimetidine
• phenobarbital, phenytoin and carbamazepine (anticonvulsant medicines).

Do you agree to the following?

• You will read the patient information leaflet supplied with your medication
• 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.
• 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.