Erectile Dysfunction | Questionnaire

Kindly Tell Us Your Age

Back

Under 18

18-25

26-69

70 or over

Back

Please select all the statements that are applicable to you

I've never experienced an erection

I've been diagnosed with cardiovascular disease

I have previously been able to maintain an erection, but I'm now unable to do so reliably.

Back

Have you had your blood pressure checked within the past 6 months?

Yes

No

Back

What was the reading of your blood pressure?

Less than 90/50 mmHg (low)

Between 90/50 and 140/90 mmHg (normal)

Above 140/90 mmHg (high)

Back

Have you tried any of the following treatments before?

Back

Viagra / Sildenafil

Cialis / Tadalafil

Both

None of the above

Back

Please share your experiences with these treatments, including any side effects you may have had.

Continue Back

Do any of the following statements apply to you?

I've had a heart attack, stroke, or mini-stroke within the past 6 months.
I have symptoms of chest pain or any heart rhythm irregularities.
I have issues with my heart valves.
I have heart muscle disease.
I become breathless or experience chest pain with light exertion, such as climbing two flights of stairs.
I've been advised to refrain from sexual activity for medical reasons.
I have or have had heart or neurological conditions.

Back

Yes

No

Back

Do any of the following medical conditions apply to you?

Serious liver problems (like cirrhosis) or kidney problems.
Currently prescribed GTN, Isosorbide mononitrate, Isosorbide dinitrate, Nicorandil (nitrates), or Rectogesic ointment.
Blood pressure abnormality (below 90/50 mmHg or above 160/90 mmHg).
A condition affecting your penis (such as Peyronie's Disease, previous injuries, or inability to maintain an erection due to shape).
Leukemia, multiple myeloma, sickle cell anemia, or a bleeding disorder (like hemophilia).
Stomach ulcers or certain eye diseases like retinitis pigmentosa.
Taking Alpha-blockers (medication for high blood pressure or prostate condition).

Back

Yes

No

Back

Are you currently on any of the following medications?

Nitrate medications (like GTN spray, isosorbide mononitrate/dinitrate for chest pain, or nicorandil).
Riociguat for pulmonary hypertension.
Recreational drugs (such as 'poppers', 'room odorizers', amyl nitrate, butyl nitrate).

Back

Yes

No

Back

Have you experienced any of the following

Loss of vision in one or both eyes.
Sudden decrease or loss of hearing.
An erection that lasted more than 4 hours (priapism).

Back

Yes

No

Back

Do you agree to the following statement?

I will promptly report any changes in my health or adverse effects to my doctor.

Back

Yes

No

Back

Are you taking any medications (including over the counter or herbal medicines)? Do you have any other medical conditions not already mentioned?

Back

Yes

No

Back

Please list all your medications you take and any other medical conditions.

Continue Back

Does any of the following statements regarding allergies apply to you?

Back

I have an allergy to a medicine or substance

I have lactose intolerance but not a lactose allergy

I have no allergies

Back

Please list any substances or medicines that you may have allergies to.

Continue Back

Our tablets contain minuscule amounts of lactose. If you have previously taken a tablet formulation without any symptoms, it's unlikely that you'll experience adverse effects from the lactose in our tablets.

I'm comfortable with proceeding to be assessed for a prescription

I can't tolerate even small amounts of lactose

Back

Please share with us any significant illnesses, ongoing medical conditions, medications (prescribed or over-the-counter) you're currently taking, allergies to medication, or surgical procedures you've undergone. This information is crucial for our clinicians to ensure the prescribed treatment is safe for you.

Back

I have a significant illness, ongoing medical condition, allergy to medication, or take prescribed or over-the-counter medication to inform you about.

I don't have a significant illness, ongoing medical condition, operation, allergy to medication, or take prescribed or over-the-counter medication to inform you about.

Back

Please provide more information about your condition or medication.

Continue Back

Would you like us to inform your GP about your treatment?

Back

Yes

No

Back

Please provide your GP's contact information?

Continue Back

On average, how often do you anticipate having sex and using these medications?

Back

Less than once per week

1-2 times per week

2-3 times per week

More than 3 per week

Back

How would you prefer to take your medication?

Before you submit your responses, please review them carefully. Our licensed clinician will go through your answers and get back to you shortly if a prescription is appropriate. By submitting this questionnaire, you are agreeing to our Terms & Conditions and Terms of Sale.

Back

1 hour before sexual intercourse

I'd rather not plan and take the tablet beforehand

Back

Thank you

For Answering

Thank you for answering questions about your health and experiences with Erectile Dysfunction. Your responses will assist our licensed clinicians in determining if a prescription for Erectile Dysfunction treatment could be appropriate for you. They will promptly review your answers and get back to you with suitable suggestions.

Before Submitting Your Answers, PleaseAcknowledge The Following:

You Are The Sole User Of Any Medication Provided Through This Service.
You Have Provided Truthful Answers To The Best Of Your Knowledge.
You Are Aware That Minoxidil 5% Solution And Combined Minoxidil 5% With 0.1% Finasteride Solution Are Prescribed As Unlicensed Products.
You Were Assigned Male At Birth.
You Have Disclosed Any Serious Illnesses Or Operations You Have Had.
You Have Disclosed Any Prescription Medication You Currently Take.
You Will Only Use The Recommended Method Of Hair Loss Treatment And Not Combine More Than One Different Medication For This Condition.
You Are Aware That You Should Not Take Finasteride If You’re Trying For A Baby.
You Accept Our Terms & Conditions, Privacy Policy, And Terms Of Sale.
You Currently Live In The UK.
You Are Using This Service Of Your Own Free Will.
Will Read all patient information leaflets available
You Agree To The Terms Of Service, Terms Of Subscription, And Privacy Policy.

Kindly Tell Us Your Age

Please select all the statements that are applicable to you

Have you had your blood pressure checked within the past 6 months?

What was the reading of your blood pressure?

Have you tried any of the following treatments before?

Please share your experiences with these treatments, including any side effects you may have had.

Do any of the following statements apply to you?

Do any of the following medical conditions apply to you?

Are you currently on any of the following medications?

Have you experienced any of the following

Do you agree to the following statement?

Are you taking any medications (including over the counter or herbal medicines)? Do you have any other medical conditions not already mentioned?

Please list all your medications you take and any other medical conditions.

Does any of the following statements regarding allergies apply to you?

Please list any substances or medicines that you may have allergies to.

Our tablets contain minuscule amounts of lactose. If you have previously taken a tablet formulation without any symptoms, it's unlikely that you'll experience adverse effects from the lactose in our tablets.

Please provide more information about your condition or medication.

Would you like us to inform your GP about your treatment?

Please provide your GP's contact information?

On average, how often do you anticipate having sex and using these medications?

How would you prefer to take your medication?

Thank you

For Answering

Before Submitting Your Answers, PleaseAcknowledge The Following:

1000+

1000+

We are creating your personalized recommendations.

This will only take couple of seconds

Erectile Dysfunction?

We’ve got you Covered

Anonymous Gent

Kindly Tell Us Your Age

Please select all the statements that are applicable to you

Have you had your blood pressure checked within the past 6 months?

What was the reading of your blood pressure?

Have you tried any of the following treatments before?

Please share your experiences with these treatments, including any side effects you may have had.

Do any of the following statements apply to you?

Do any of the following medical conditions apply to you?

Are you currently on any of the following medications?

Have you experienced any of the following

Do you agree to the following statement?

Are you taking any medications (including over the counter or herbal medicines)? Do you have any other medical conditions not already mentioned?

Please list all your medications you take and any other medical conditions.

Does any of the following statements regarding allergies apply to you?

Please list any substances or medicines that you may have allergies to.

Our tablets contain minuscule amounts of lactose. If you have previously taken a tablet formulation without any symptoms, it's unlikely that you'll experience adverse effects from the lactose in our tablets.

Please provide more information about your condition or medication.

Would you like us to inform your GP about your treatment?

Please provide your GP's contact information?

On average, how often do you anticipate having sex and using these medications?

How would you prefer to take your medication?

Thank you For Answering

Before Submitting Your Answers, PleaseAcknowledge The Following:

1000+

1000+

Your safety is our top priority.

Unfortunately, we can’t offer you any Erectile Dysfunction medication.

Did you make a mistake?

We are creating your personalized recommendations.

This will only take couple of seconds

Erectile Dysfunction?

We’ve got you Covered

Anonymous Gent

Thank you

For Answering

Your safety

is our top

priority.