Erectile Dysfunction

- tell us about your condition

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What is your gender?

Do you need help completing this questionnaire?

Yes

Do you believe that you have the capacity to make decisions about your own healthcare?

Yes

Sorry we can't offer you this treatment, please contact your GP.

Have you been diagnosed with any medical conditions?

Yes

Please provide more detail.

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.

Yes

Please provide more detail.

Do you suffer from any allergies?

Yes

Please provide details including which allergies and what symptoms you experience.

Is there anything else you would like to include to allow our prescriber to prescribe responsibly?

Yes

Please provide more detail.

Are you currently prescribed any GTN spray, tablets, patch, gel or cream or take nicorandil or any nitrate tablets (usually prescribed for heart conditions)?

Yes

Please provide more information

Do you drink or smoke?

Yes

Please be aware that alcoholic drinks and/or smoking can cause erection difficulties. We offer smoking cessation services through our website.

Do you persistently have trouble achieving or maintaining an erection when sexually aroused?

Yes

Please provide more details

Do you suffer from any issues with your heart, liver,kidneys or have diabetes?

Yes

Please provide more details

Have you had a heart attack or stroke in the last 6 months?

Yes

Please provide more details

Do you get breathless or suffer from chest pain with light activity such as going up two flights of stair or walking at a fast pace for five minutes?

Yes

Please provide more details

Do you suffer from low blood pressure (below 90/50) or experience faints or collapsing because of it?

Yes

Please provide more details

Do you have any conditions affecting the shape of your penis?

Yes

Please provide more details

Have you ever experienced an erection lasting longer than 4 hours?

Yes

Please provide more details

Do you have any issues affecting your heart rhythm?

Yes

Please provide more details

Do you suffer from any eye conditions such as non-arteric ischaemic optic neuropathy, retinal problems or retinitis pigmentosa?

Yes

Please provide more details

Do you suffer from stomach/duodenal ulcers or blood conditions such as sickle cell, haemophilia or bleeding disorders?

Yes

Please provide more details

Have you ever had an allergic reaction to any erectile dysfunction medicine?

Yes

Please provide more details

Do you agree to the following:

I understand that all men with erectile dysfunction are recommended to have their blood pressure checked regularly as well as having blood tests for high cholesterol, diabetes, and hormone imbalances (such as thyroid, testosterone or prolactin)

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 a new medication or if your medical conditions change during treatment
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

Confirm

Would you like us to notify your GP of the treatment you chose to order today?

Yes

GP Practice Name, GP Postcode, GP Telephone Number

GP Information

Please provide your GP surgery details.

Consent & Declarations

I confirm that my answers are true and accurate and that I have read and agree to the Terms and Conditions and Privacy Policy.

Its required to fill all details.

Do you agree to the following:

You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You are aware you will be subject to a soft check to validate your identity via Experian
You will read the Patient Information Leaflet supplied with your medication
You agree to Cloud Pharmacy terms and conditions and privacy policy.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
You will inform your GP of this purchase if appropriate

Yes

Sorry we can't offer you this treatment, please contact your GP.

Please complete all required questions.

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