ED Medication Kaybox Step 1 of 3 – Your Details 0% Your DetailsAre you registered with a GP practice in the UK?(Required) Yes No 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 No 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 No 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 No Please provide more information, including diagnosis, symptoms and treatment.Is there anything else you would like to include for the prescriber?(Required) Yes No If so, Please provide more informationPlease 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 QuestionsThe 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 No 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]. Do you have any diagnosed medical conditions?(Required) Yes No 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 No 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 No 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]. Do you suffer from any allergies? This includes any medication or ingredients you may be allergic to?(Required) Yes No 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 No Can you always get an erection when you need?(Required) Yes No Can you always keep an erection for as long as you need?(Required) Yes No Can you always get an erection that is hard enough for penetration?(Required) Yes No 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 No Do you have low blood pressure (below 90/50)?(Required) Yes No 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 been advised to avoid strenuous exercise?(Required) Yes No Would you have any difficulty walking at a fast pace for 5 minutes?(Required) Yes No Do you suffer from depression for which you have not seen a GP?(Required) Yes No 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 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]. 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 No 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 No 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 been told by a doctor to avoid physical or sexual activity?(Required) Yes No 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]. Do you suffer from depression for which you have not seen a GP?(Required) Yes No 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 had a heart attack or a stroke in the past 6 months?(Required) Yes No 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]. Do you have any medical conditions affecting the eye?(Required) Yes No 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 No Are you currently taking any medication?(Required) Yes No 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 AcknowledgementsBy 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 No 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 No 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 aboveConsent(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.
