Erectile Dysfunction

• Heart conditions or had any major health incidents involving the heart? (e.g. Heart attack or stroke)
• Kidney Problems
• Liver Problems
• Stomach or Duodenal Ulcer
• Vision Loss due to optic nerve damage or poor circulation
• Retinitis Pigmentosa
• Myeloma, leukaemia, sickle cell disease
• Inflammation or any physical abnormality of the penis.
• An erection that lasted more than 4 hours

If yes, please list your medical conditions.

If yes, please describe the product/reaction.

• Any treatment for erectile dysfunction apart from sildenafil , vardenafil or tadalafil
• Medicinal nitrates such as glyceryl trinitrate, nicorandil, isosorbide mononitrate or isosorbide dinitrate (including oral, transdermal and sublingual)
• Recreational drugs
• Recreational nitrates such as "poppers"
• Alpha blockers (such as alfuzosin, tamsulosin, doxazocin, prazocin terazocin & indoramin)
• Blood thinning medicines including anticoagulants, antiplatelets or Warfarin
• Anti-virals (such as indinavir, nelfinavir, ritonavir, saquinavir)
• Anti-fungals (such as Ketoconazole or itraconazole)
• Quinidine, procainamide, amiodarone
• Theophylline, cimetidine
• Anticonvulsants (such as phenobarbital, phenytoin and carbamazepine)
• Erythromycin, Clarithromycin, Riociguat, Rifampicin

• To Inform both us and your GP about any treatment-related side effects, the initiation of new medication, or changes in your medical conditions during the course of treatment.
• You must read the patient information leaflet provided with your medication before using your new treatment. If you have any questions you can contact our support team or your GP.
• The prescribed treatment is intended exclusively for your personal use.
• You have provided accurate and truthful responses to all the preceding questions.
• You acknowledge that our prescribers rely on your responses as truthful and honest to make prescribing decisions and recognise that inaccurate information may result in serious health risks.