Assessment Erectile Dysfunction

Step 1 of 3 - Your Details

Your Details

Are you registered with a GP practice in the UK?(Required)

Yes

If not, Why are you not registered with a GP practice?

Do you give us consent to write to your GP to share information of this supply and any information we hold about you?(Required)

Yes

Please enter the name and address of your GP practice.

Do you believe you have the capacity to make decisions about your own healthcare?(Required)

Yes

Unfortunately, we cannot recommend a suitable treatment for you. If you did this in error, you have the choice to change your answer. If you have any questions about this consultation, please email [email protected].

Have you ever been diagnosed with a mental health condition?(Required)

Yes

Please provide more information, including diagnosis, symptoms and treatment.

Is there anything else you would like to include for the prescriber?(Required)

Yes

If so, Please provide more information

Please upload your Photo Identification (if you have uploaded in the last 3 months this is not required) please note, we will not be able to process your order if this is not complete.

Max. file size: 80 MB.

Medical Questions

The information you provide us is treated with the utmost confidentiality and will be reviewed by a registered doctor. The questions listed are to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.

Are you between 18 and 70 years old?(Required)

Yes

Do you have any diagnosed medical conditions?(Required)

Yes

Please provide details.(Required)

Do you take any medication? This can be prescribed medication or any other over the counter or herbal medicines?(Required)

Yes

Please provide details.(Required)

Are you taking any medicines known as nitrates (often taken for chest pain/angina) or nitric oxide donors ('poppers')?(Required)

- Can be administered as a spray, tablet or patch. - Include glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate

Yes

Do you suffer from any allergies? This includes any medication or ingredients you may be allergic to?(Required)

Yes

Select the allergies or sensitivities you have:(Required)

Select one or more answers

Nuts

Soya

Lactose

Other

Please provide details.(Required)

Have you taken any Erectile Dysfunction treatments before?(Required)

Select one or more answers

Viagra (sildenafil)

Cialis (tadalafil)

Levitra (vardenafil)

Spedra (avanafil)

I haven't taken ED treatment before

Do you have trouble achieving or maintaining your erection?(Required)

Yes

Can you always get an erection when you need?(Required)

Yes

Can you always keep an erection for as long as you need?(Required)

Yes

Can you always get an erection that is hard enough for penetration?(Required)

Yes

Please provide further information on why you need the treatment(Required)

Do you have high blood pressure (above 160/90), or are you currently on treatment for high blood pressure?(Required)

Yes

Do you have low blood pressure (below 90/50)?(Required)

Yes

Have you been advised to avoid strenuous exercise?(Required)

Yes

Would you have any difficulty walking at a fast pace for 5 minutes?(Required)

Yes

Do you suffer from depression for which you have not seen a GP?(Required)

Yes

Have you ever been diagnosed with one of the following conditions:(Required)

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)

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

None of the above

Please provide any additional information that you think we need to know about to safely prescribe your medication (optional)

Have you ever had a painful erection?

Yes

What was this caused by?(Required)

Select one or more answers

Peyronie's disease

Scarring or bend of the penis

Trauma or injury to the penis

Unable to retract the foreskin (phimosis)

Foreskin stuck behind the head (paraphimosis)

Deformed or bent penis

Other

Do you often get breathless or have chest pain when you do light movements, like walking from one room to another or up the stairs?(Required)

Yes

Have you been told by a doctor to avoid physical or sexual activity?(Required)

Yes

Do you suffer from depression for which you have not seen a GP?(Required)

Yes

Have you had a heart attack or a stroke in the past 6 months?(Required)

Yes

Do you have any medical conditions affecting the eye?(Required)

Yes

Do any of the following apply:(Required)

You have any medical conditions that you have not already mentioned
You have, or previously had, any mental health problems that required specialist mental health support or hospitalisation
You have had major surgery
You have heart problems or have had a stroke
You have decreased kidney or liver function

Yes

Are you currently taking any medication?(Required)

Yes

Please provide details of any medication you are currently taking(Required)

Do you take any of the following medications?(Required)

Select one or more answers

GTN spray

Nitrates (such as isosorbide mononitrate or dinitrate to treat angina)

Nicorandil

Erythromycin

Riociguat (to treat pulmonary arterial hypertension)

Protease inhibitors (including ritonavir indinavir nelfinavir and selquinavir - to treat HIV)

Alpha blockers (including alfuzosin indoramin terazosin prazosin doxazosin and tamsulosin)

Amyl nitrate (poppers)

Baclofen

None of the above

Do you have any of the following conditions?(Required)

Select one or more answers

Sight in only one eye

NAION (Non-arteritic anterior ischemic optic neuropathy)

Retinitis pigmentosis

None of the above

Do you have any of the following:(Required)

Select one or more answers

Bleeding disorder such as haemophilia

Active stomach peptic or gastric ulcers

Sickle cell disease

Leukaemia or multiple myeloma

None of the above

Acknowledgements

By providing your consent, you acknowledge that you understand and agree to the treatment plan and associated terms below.

I understand that there are a number of conditions that can cause erectile dysfunction e.g. hypertension, diabetes mellitus, high cholesterol or heart disease and I should consult my doctor within 6 months of starting treatment for a clinical review.(Required)

I confirm the above

Yes

In the rare event, I obtain a prolonged erection of more than 4 hours or experience any sudden visual impairment, or experience any chest pains, I agree that I will seek immediate medical assistance.(Required)

I confirm the above

Yes

I confirm I am over 18 years old and 80 years old.
The medicine being requested is to be used solely for my own use.
I will read the patient information leaflet supplied with the medication.
I take responsibility to inform my own regular GP of the online consultation, any medication issued or any changes in my symptoms or medical conditions.
I agree to contact my GP if there is no relief of symptoms after 14 days or if my symptoms are worsening
I have answered all the questions truthfully and accurately.
I understand that the final decision to issue the medication lies with the prescriber. At this stage, my request still needs to be reviewed and approved by the prescriber, therefore there is no guarantee that a prescription will be issued.
I confirm I have the capacity to make decisions about my own health.
I have read and agree to the terms and conditions of Newtons Chemist

Confirmation(Required)

I confirm the above

Consent(Required)

I confirm the details are true and I consent to processing my health data.

Please confirm you agree the following:(Required)

Do you consent to us requesting further information on your medical history from your GP? This is to ensure that any treatment we recommend for you is appropriate and safe. For full details, please click the
"Need help?" link below. Any references to "we" or "us" refers to ABSM Healthcare Limited.

I confirm the above

Consent(Required)

Do you consent to us accessing your NHS Summary Care Record (the medical details held by your GP) or requesting further information on your medical history from your GP?

One or more of your answers means this online service is not suitable for you. You will not be able to complete this form. Please contact your GP or another healthcare professional.