Treatment Questions – Your Chemists

Erectile dysfunction subscriptions
Consent

Our doctors would now like to check your suitability for this product

What is your sex?

Male Female

What is your date of birth?

Date

Month

Year

How did your ED begin?

Suddenly Gradually

Do you get normal erections in the mornings or when you masturbate?

Yes No

Has your sex drive gone down?

Yes No

Do you have, or have you ever had, any heart conditions?

Yes No

Have you ever had a stroke or mini-stroke (TIA)?

Yes No

Have you had a stroke or mini stroke (TIA) within the last 6 months?

Yes No

Do you ever experience any of the following?

Chest pains Shortness of breath on mild exercise Palpitations Dizzy spells Needing to stop after 15 minutes of walking on flat ground None of the above

Are you waiting for any investigations, treatments or procedures for your heart condition?

Yes No

Do you have a blood clotting condition that increases your risk of having blood clots, such as sickle cell anaemia, multiple myeloma or leukaemia?

Yes No

Do you have a condition that affects your blood\'s ability to clot and makes you more prone to bleeding?

Yes No

Have you ever had a liver condition?

Yes No

Have you ever had a kidney condition?

Yes No

To help us advise on the best treatment for you, please tick if you have any of the following:

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

A thickened area or hard lump in the shaft A significant curve in the penis when it's erect Difficulty retracting foreskin Painful erection I have had penile implant surgery I have had priapism None of the above

During the last month have you been feeling down or had little interest or pleasure in doing things?

Yes No

Do you take medicines for any of the following conditions?

HIV Premature ejaculation Blood pressure Depression or anxiety Pain (codeine or tramadol) Hair loss (Finasteride) None of the above

Are you taking any of the following medication?

And finally, are you taking any prescription medications that you have not already told us about?

Yes No

Have you ever taken ED medication before and had an allergic reaction?

Yes No

Have you ever taken ED medication before and had side effects?

Yes No

How many days a week do you drink alcohol?

I don't drink or rarely drink 1 to 2 3 4 5 6 7

Do you smoke?

Yes No

Do you use cannabis?

Yes No

Do you use any other recreational drugs such as cocaine or ecstasy?

Yes No

Please enter your height(cm).

Please enter your weight(kg).

We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

I confirm the above Please confirm the following to complete your consultation:

--I have responded honestly and provided complete and accurate information that reflects my up to date medical history and information, so that the clinician can safely assess and advise me.
--I fully understand all the questions and information provided. If I am unsure about any aspect of the service I will contact before proceeding.
--I understand the side effects, effectiveness and alternatives to the treatment I am requesting.
--I understand the importance of notifying my GP about medicines and advice I may receive from this service so they can continue to provide safe medical care.
--I understand this consultation will form part of my Online Doctor medical record and will be kept in line with the relevant retention period.
--I have read, understand and agree to the terms and conditions and privacy policy

I confirm the above

Erectile dysfunction subscriptions

Our subscription service makes it simple to get the medication you need. With free discreet delivery or ParcelShop collection, no repeat ordering and no hidden costs, simply order your treatment and save 15% every time.

0% of questionnaire complete