ED prescription questionnaire

Welcome! This questionnaire forms the basis of your online consultation. Please be honest and if you are unsure about any of your answers please verify the information with your GP before using the service:

Name *

First

Last

Date of Birth *

Email *

Address *

I am 18 years old or above

I am using this service on my own behalf and of my own free will

What´s your birth gender? *

Male
Female

Which drug are you looking for? *

Sildenafil (generic viagra) - on demand
Viagra - on demand
Tadalafil (generic Cialis) - on demand
Tadalafil (generic Cialis) - daily
Cialis - on demand
Cialis - daily
Spedra

Please choose the dosage. Usual starting dose is 50 mg *

25mg
50mg
100mg

Please choose the dosage. Usual starting dose is 50 mg *

25mg
50mg
100mg

Please choose the dosage. Usual starting dose is 10 mg *

10mg
20mg

Why do you need this higher dosage? *

Please choose the dosage. Usual starting dose is 5mg/day *

2,5mg
5mg

Please choose the dosage. Usual starting dose is 10 mg *

10mg
20mg

Why do you need this higher dosage? *

Please choose the dosage. Usual starting dose is 5mg/day *

2,5mg
5mg

Please choose the dosage. *

50mg
100mg
200mg

Select Pharmacy to where prescriptions should be sent. Select "other" if you can't find your pharmacy *

Please select only one answer. The one that best describes your situation over the last six months:

1. How do you rate your confidence that you could keep an erection? *

Very low
low
Moderate
High
Very high

2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)? *

Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (more than half the time)
Almost always or always

3. Over the las six months: During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? *

Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (more than half the time)
Almost always or always

4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? *

Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult

5. When you attempted sexual intercourse, how often was it satisfactory for you? *

Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (more than half the time)
Almost always or always

6. Have you ever used any treatment for erectile dysfunction? *

Which treatments have you used? *

Were these effective? *

Do you experience any side effects? *

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

Painful erection
Peyronie´s Disease
Significant bend to the penis
Priapism
None of the above

8. Do you think you may also suffer from premature ejaculation? *

Medicines used for the treatment of erectile dysfunction will not treat premature ejaculation but may help if you are having problems getting or maintaining an erection. *

Please confirm that you understand this.

9. Do you have a heart condition or have you had one in the past? *

Provide details *

10. Do you experience any of the following symptoms? *

Chest pains
Shortness of breath on mild exercise
Palpitations (heart racing)
Dizzy spells
After walking 15 minutes on flat ground you need to stop
None

Please give details *

11. Do you experience any problems with your blood pressure? *

Yes - I have hypertension under treatment
Yes - I have high blood pressure but not taking any drugs for it
Yes - I have low blood pressure
No blood pressure problems

Please tell me more about this *

The medication you have requested can have serious side effects if your blood pressure is below 90/50. Is your blood pressure below 90/50? *

12. Please provide your last BP reading *

13. Have you been told by a doctor to avoid physical or sexual activity in the last six months? *

14. Have you ever had a stroke or mini stroke (TIA)? *

Was this in the last six months? *

15. Do you have diabetes? *

Diabetes contributes to erection problems. A good Diabetes control may have a positive effect on ED symptoms.

16. Do you have a liver condition, or have you had one in the past? *

Please provide details *

17. Do you have a kidney condition, or have you had one in the past? *

Please provide details *

18. Do you have any of the following eye conditions? *

Retinitis Pigmentosa
Non-arteritic ischaemic neuropathy
Sudden loss of vision in one eye
None

19. Have you been diagnosed with a stomach or duodenal ulcer in the past six months? *

Please provide more details *

20. Do you have any blood conditions such as: myeloma, leukaemia, sickle cell disease or haemophilia? *

Please provide more details *

21. Other than those already mentioned, do you have any other significant medical conditions, illnesses, hospital stays or past surgical procedures? *

Please provide more details *

22. Are you taking any of the following medications? *

Alpha blockers (alfuzosin, prazosin, doxazosin, tamsulosin). These are used to reduce blood pressure or treat prostate problems
GTN Spray or tablets
Isosorbide medicines
Nicorandil
Blood thinning medicines (aspirin, clopidrogel, warfarin or heparin)
None

23. Are you taking any other prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs? *

Please provide more details *

24. Do you use poppers (amyl nitrate) recreationally? *

25. Do you smoke? *

26. Do you drink alcohol? *

Alcohol can make it more difficult to get an erection. Limit alcohol to one
glass of wine or beer when using this medication. If you are consistently
drinking more than the recommended 14 units of alcohol per week then seek
help from your GP or local alcohol dependency services

27. Do you have any known allergies, including drug induced allergies? *

Please provide more details *

28. I want to check your understanding of erectile dysfunction. Please tell me: A healthy lifestyle and well controlled blood pressure can help with erectile dysfunction in addition to your treatment. *

True
False

29. Before we finish, is there anything else you want to tell me?

Checkboxes *

Please confirm that you understand the questions asked, have answered them honestly, and that this treatment is for yourself only. You understand the side-effects, other treatment options available, and that you can message us for more information.

Price

Total Amount: 25 €

Pay with a Debit or Credit Card *

Card

Name on Card

Get a Prescription for Erectile Dysfunction