Erectile dysfunctionConsultationComplete this form in order to see what types of erectile dysfunction treatments you are eligible for. Step 1/7: Start Leave this field blank Answer these questions to get the most effective clinically proven treatments for you. Full Name Date of Birth Email Please provide an email address so we can contact you furhter regarding enquiries Phone Number Please provide a number so we can contact you furhter regarding enquiries Gender at Birth Male Female Are you allergic to any of the following medication? Avanafil (Spedra) Sildenafil (Viagra) Tadalafil (Cialis) Vardenafil (Levitra) I am not allergic to any of these Do any of the following statements apply to you? I have had a heart attack/ stroke/ myocardial infarction in the last 6 months? I get chest pains or shortness of breath while walking short distances I have a kidney or liver disease I am waiting for a organ transplant I have low blood pressure or an irregular heartbeat I suffer from: Anaemia, Myeloma, Leukaemia or Sickle cell disease I have hereditary degenerative retinal disorders I have a history of non-arteric anterior ischaemic optic neuropathy I have been diagnosed with Peyronie’s disease or suffer from penile deformity/angulation. I have been advised to refrain from intense activity such as sexual intercourse. None of these Do you take any of the following medications? Amyl Nitrate Cimetidine Citalopram or Escitalopram Diltiazem, Verapamil, Amiodarone Doxazosin / Tamsulosin / Alfuzosin / Terazosin / Prazosin Erythromycin or Clarithromycin Fluconazole / Itraconazole, Ketoconazole, Miconazole, Voriconazole Glyceryl Trinitrate (GTN) Spray Indoramin Indinavir, Tipranavir, Atazanavir, Darunavir, Fosamprenavir or Saquinavir Isosorbide mononitrate or Dinitrate Nicorandil Nilotinib, Lapatanib, Pazopanib, Sunitinib Rifampicin None of these Are you, or have you taken any of these Erectile dysfunction treatments? Herbal / Ayurvedic remedies Penile pumps Penile injections (Caverject / Edex / Prostin VR) Levitra / Vardenafil Spedra / Avanafil Sildenafil - Viagra Tadalafil - Cialis None of these Do you take any recitational drugs, including any nitrate based drugs eg: Poppers? Yes No Please provide further details Do you have any other medical conditions? If so list them below as well as any medications you are currently taking. If you don't have anything to add, just click next. DO YOU AGREE AND CONSENT TO THE FOLLOWING? • I am over the age of 18 years and live in the UK.• I will familiarise myself with the patient information leaflet included with the medication.• I will report any side effects and changes in my health to Bury Healthcare Online and/or your GP.• I will contact Bury Healthcare Online and inform my GP if I experience side effects to any treatment, if my medical history changes, if I start any new medications or if I experience any symptoms or my medical conditions change in any way.• I shall be the sole user of any medication offered to me through this service.• I confirm all answers are provided by me, and will be truthful. I agree to the terms and conditions Next
