Are you registered with a GP practice in the UK?
Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost
confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with
important information which will help them make an informed decision in deciding if the
treatment is considered to be suitable for you).
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 drink alcohol?
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?
Do you have low blood pressure (below 90/50)?
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?
Are you taking any medicines known as nitrates (often taken for chest pain/angina) or nitric oxide donors ('poppers')?
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
Are you taking any of the following medications?
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?