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Assessment Progress

1Your Erectile Dysfunction (ED)
2Your Health
3Consent

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Assessment

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We have recently updated our assessment form to ensure that it continues to provide a safe, holistic consultation for our patients. Please fill it out carefully and honestly.

1Your Erectile Dysfunction (ED)

Do you have difficulty getting an erection or maintaining an erection? *

NoYes

This service is only for patients who are having difficulty getting or maintaining an erection. You must confirm this before you can proceed.

This problem can affect men at different times and for various reasons, for example when you're tired, have had a drink or with a new partner. If you feel you have a different medical issue, please speak to your GP or local sexual health clinic.

It is important to speak to your GP about your Erectile Dysfunction (ED).

If you feel there is a psychological cause to your Erectile Dysfunction, which is typically characterised by the ability to have early morning and nocturnal erections but the inability to achieve or maintain an erection during a sexual encounter with a specific partner, you may find counselling beneficial. Please consider discussing this with your GP and seeking further support.

If you are unable to achieve early morning or nocturnal erections, or unable to get an erection at all, then this may be a sign of an underlying health issue such as a cardiovascular (heart) issue, diabetes or hormone issue and we recommend you speak to your GP about the need for further investigations, testing and a general health check

Please tick to confirm you understand: *

Confirm

What was your sex registered at birth? (i.e. your biological sex) *

2Your Health

Are you taking any nitrate medications such as glyceryl trinitrate (GTN) spray, tablets, patches or ointment; isosorbide mononitrate; isosorbide dinitrate; nicorandil or recreational amyl nitrate ('poppers')?

WARNING: There can be a fatal reaction between erectile dysfunction medication and these medications*

NoYes

Are you taking any of the following medications? *

RiociguatQT prolonging drugs (quinidine, procainamide, amiodarone and sotalol)CYP3A4 inhibitors: (ritonavir, saquinavir, indinavir, atazanavir, itraconazole, ketoconazole, clarithromycin, erythromycin, cimetidine and grapefruit juice)CYP3A4 inducers: (rifampicin, phenobarbital, phenytoin and carbamazepine)Sacubitril/valsartan (brand Entresto)None of the above

Are you taking medicines called Alpha-blockers (eg alfuzosin, prazosin, doxazosin, tamsulosin) which are normally used for blood pressure or prostate problems? *

NoYes

Which of the following applies regarding your use of Alpha-blockers? *

If your medication or dose changes, we would advise that you stop ED treatment and speak to your GP

Are you taking 5-alpha-reductase inhibitors (for example Finasteride or Dutasteride) for hair loss? *

NoYes

ED is a known side effect of 5-alpha-reductase inhibitors and could potentially compound the risk of mental health issues while taking these medications. Do you believe your ED is being caused by Finasteride/Dutasteride? *

NoYes

Apart from those already declared, do you take any other prescription, non-prescription or recreational medication? *

NoYes

Please list any other prescription medicines you are taking *

Do you have any of the following conditions affecting your penis? *

Anatomical deformation (eg angulation, curvature, cavernosal fibrosis, peyronies)History of recurrent priapism or conditions which predispose to it (prolonged erection of the penis)Sickle cell anaemia, multiple myeloma, leukaemia, thrombocythemia or polycythaemiaPainful erections or penile implantsBalanitisAcute or chronic urethritisHypospadiasNone of the above

Do you suffer from any of the following conditions *

Have you suffered from any of the following events in the last 6 months? *

You should have your blood pressure checked before taking this medication. If your blood pressure is more than 170/100mmHg or less than 90/50mmHg, this medication is not suitable for you. You can have this checked at your GP or your local pharmacy. Please tick to confirm that you will have your blood pressure taken, and you will check you are within this range, before taking the medication: *

Confirm

Have you been advised by a doctor to avoid sexual activity or strenuous exercise due to the health of your heart? *

NoYes

Do you have any of the following conditions? *

Weakened liver functionWeakened kidney functionActive peptic ulcerationHistory of gastrointestinal disease, including erosive gastritis; gastrointestinal bleeding and gastric and/or duodenal ulcerNone of the above

Do you have any of the following eye conditions? *

Do you have any allergies or sensitivities? *

NoYes

Please give more details *

Do any of the following statements concerning your overall health and lifestyle apply to you? *

Being overweight can result in Erectile Dysfunction directly as well as indirectly. It does so indirectly by leading to high blood pressure, heart disease, diabetes and lower testosterone levels. Therefore, trying to tackle your weight is a beneficial step in helping your Erectile Dysfunction.

A healthy lifestyle, including a diet rich in fruit and vegetables and at least 150 minutes of moderate intensity activity a week or 75 minutes of vigorous intensity activity a week may help with Erectile Dysfunction.

Nicotine is known to cause Erectile Dysfunction and therefore stopping smoking offers an important step in helping your Erectile Dysfunction. We also offer a Stop Smoking Service via our online doctors.

Drinking large amounts of alcohol is known to cause Erectile Dysfunction and it is therefore important to reduce alcohol intake and not to drink more than 14 units of alcohol per week.

Is there any other information you feel would be useful for our clinicians to know about? *

NoYes

Please provide more information below: *

3Consent

We strongly advise that you inform your GP of any treatment you receive.
Would you like us to inform them on your behalf?*

NoYes

Please enter your postcode to display your local GP's

Please enter your GP’s name and surgery address. Please also enter their email address and fax number, if you know it.

You can find your GP surgery information details below

Please enter your GP surgery name *

Please enter your GP surgery address and post code *

Please enter your GP surgery email

Do you understand that you must NOT use more than one treatment for Erectile Dysfunction at any time? Please tick to confirm: *

Confirm

NOTE: If trialling ED medicines, please note that if ordering more than 8 of one medicine, we will not issue more than 8 of the second. Placing an order for more than this quantity will delay your order as we will need to contact you to determine your preference and amend your order. If you do order more than 1 ED medication, we may contact you regarding this order.

Please tick to confirm that you are aware: If ordering sildenafil/Viagra the maximum dose is 100mg at one time and the maximum dose of tadalafil/Cialis is 20mg at one time. *

Confirm

If you are ordering Avanafil (Spedra), please tick to confirm you are aware that consumption of alcohol in combination with Avanafil can potentially drop your blood pressure and thereby increase your likelihood of experiencing dizziness and fainting episodes. As such we advise you not to take Avanafil and Alcohol together. *

Confirm

If you are selecting Vitaros cream as your treatment choice for your Erectile Dysfunction please tick to confirm you understand the following:

I am aware that latex based condoms should be used if my partner is of child-bearing potential, pregnant or breastfeeding.
I am aware that Vitaros should be stored in a refrigerator (2-8C) upon receipt of delivery.
Unopened sachets may be kept out of the refrigerator (at a temperature below 25C) for up to 3 days prior to use.
Product must be stored in its original sachet in order to protect it from light.

Confirm

Please tick to confirm that you agree to seek urgent medical attention if you experience any of the following symptoms:

A continuous erection which persists for longer than 4 hours
Blurred vision
Sudden decrease or loss of vision in one or both eyes
Chest pain

Confirm

I confirm I am a male over 18 years old.

I confirm this treatment is for me, and I consent to this treatment.

I have understood the questions and have answered these honestly.

I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.

I take responsibility to inform my own GP of the online consultation or any changes in my circumstances.

I agree to the Simple Online Pharmacy terms and conditions. *

Confirm

If you require a particular manufacturer of medication, please contact us by email after placing your order ([email protected])

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

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