ABOUT YOU

    YOUR SYMPTOMS

    YOUR HEALTH

    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) or multiple myeloma (cancer of bone marrow)
    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

    YOUR MEDICATION

    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

    *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 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).

    AGREEMENT

    Do you agree with the following?

    *You will read the patient information leaflet supplied with your medication
    *You fully understand the questions in this questionnaire and have answered honestly and truthfully
    *You fully understand the side effects of the treatment options, their effectiveness and alternative options, and are happy to continue with your request
    *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.
    *You confirm and agree that any treatment prescribed for you is for your personal use only
    understand that you should not take more than one type of ED medication on the same day
    *You give permission to access you NHS Summary Care Record in order to identify you correctly, check your medical history and provide the best possible care
    *You give permission to contact your GP to inform them of your treatment
    *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.

    [wpb-pcf-button]