About You
Are you aged 18 years or over?
Please read the introduction page before continuing. You can then change your answer and continue.
Are you a male?
Erectile Dysfunction medication are for males only.
You are eligible for treatment.
Is the medication you have selected for your own use?
Our doctor can only prescribe medicine to you.
You are eligible for treatment.
Current Symptoms
Do you have difficulty in getting and/or maintaining an erection?
This could be sometimes or always
Have you had difficulties with erections for more than a year?
Do you have any other symptoms?
Past Medical History
You must have had your blood pressure checked by your
What is your most recent blood pressure reading? Reading :
Reading
High-140/90 or Above
Normal-90/60 to 139/89
Low-89/59 or Below
Month-Year :
Month-Year
May-2012
April-2012
March-2012
February-2012
January-2012
December-2011
November-2011
October-2011
September-2011
August-2011
July-2011
June-2011
Our doctor can not prescribe medicine to you, please see your own doctor.
Please read the introduction page before continuing. You can then change your answer and continue.
Do you take any of the following?
Any medication for erectile dysfunction (apart from Viagra, Cialis, Levitra)
Nitrate containing medication such as glycerol trinitrate,
Isosorbide mononitrate, and isosorbide dinitrate usually used to treat condition such as angina.
Ritonavir or Indinavir or medicines for HIV
Ketoconazole or Itraconazole or other anti-fungal medicine
Recreational drugs eg Poppers (amyl nitrates)
Alpha blockers used to treat high blood pressure
or enlarged prostate such as Alfuzosin, Doxazosin indoramin, Prazosin, Tamsulosin, Terazosin
Our doctor can not prescribe medicine to you, please see your own doctor.
Please read the introduction page before continuing. You can then change your answer and continue.
Are you currently taking any other medication?
Have you been diagnosed with any of the following?
Allergy or reaction to previous impotence treatments
Heart disease including recent heart attack or angina (Heart pain on exertion)
History of stroke or mini stroke (Transient ischaemic attack)
History of vision problems due to poor circulation
Rare inherited eye disease (retinitis pigmentosa)
Family history of the degenerative eye disease (rare)
Serious kidney/renal or liver disease
Deformity or angulation of the penis (Peyronie’s disease)
Sickle cell disease or leukaemia or multiple myeloma
A bleeding disorder (Such as Haemophilia)
Active stomach ulcers (Also known as peptic ulcer or gastric ulcer
Our doctor can not prescribe medicine to you, please see your own doctor.
Please read the introduction page before continuing. You can then change your answer and continue.
Do you have any other medical problems?
Lifestyle Questions
Do you smoke or drink more than 21 units of alcohol per week?
Is your Body Mass Index (BMI) over 30?
Use the BMI calculator here
Have you been advised to avoid vigorous exercise?
e-g due to severe heart failure or unstable angina
Our doctor can not prescribe medicine to you, please see your own doctor.
Please read the introduction page before continuing. You can then change your answer and continue.
Are you aware that if you have a continuous erection for more than 4 hours or more you should seek immediate medical attention?
This is a very rare side effect and in the unlikely
event of this occurring seek medical attention straightaway.
If there is any further information you feel may be relevant please enter it in the box below:
Do you confirm?
You will read the patient information leaflet that will come with the medicine supplied
You have answered the above questions honestly and in full.
You are permitted by law to receive the medication in your country
You will accept full responsibility for the use of the medicine you have ordered
You are aware that you should inform your GP about erectile dysfunction
You have read the About Erectile Dysfunction page
You read and agreed to the terms of conditions page
Our doctor can not prescribe medicine to you, please see your own doctor.
Please read the introduction page before continuing. You can then change your answer and continue.
