Which best describes your erection problem?

How long have you had this problem?

Have you previously used treatment for erectile dysfunction?

For example sildenafil, tadalafil, avanafil or Viagra

Are you currently taking, or likely to need, any of the following medicines or substances?

• Nitrate medicines for chest pain or heart problems such as GTN spray, isosorbide mononitrate or isosorbide dinitrate
• Riociguat
• Recreational poppers
• Alpha blockers such as tamsulosin, alfuzosin, doxazosin or terazosin

Do any of the following medical conditions or history apply to you?

• Angina, chest pain on exertion, or you have been told sexual activity is not safe for you
• Heart attack in the last 3 months
• Stroke in the last 6 months
• Low blood pressure, or uncontrolled high blood pressure
• Significant heart failure or serious heart disease
• Loss of vision in one eye due to poor blood flow, or an inherited retinal condition
• Severe liver disease
• Severe kidney disease

Do any of the following apply to you?

• Sickle cell disease
• Leukaemia
• Multiple myeloma
• Peyronie’s disease, penile curvature, or another significant penile abnormality
• Severe pelvic or genital pain
• An erection lasting more than 4 hours

Do you have any allergies to sildenafil, tadalafil, avanafil, or any other medicines?

Please list all regular medicines you take

Please include prescribed medicines, over the counter medicines, inhalers, creams, supplements and herbal products

Understanding of Risks & Confirmation

• I understand that erectile dysfunction medicines must not be taken with nitrate medicines or poppers.
• I understand that I must seek urgent medical help if I develop chest pain after taking treatment, sudden loss of vision or hearing, or an erection lasting more than 4 hours.
• I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.
• I understand that a prescriber or pharmacist may need to contact me or my GP before treatment can be supplied.