Are you male and ages between 18-75?

Yes No

Do you smoke or drink?

Yes No

Have you used any Erectile Dysfunction medication before?

Yes No

Please state what have you tried and strength of medication.

Yes No

Do you have trouble achieving or maintaining your erection?

Yes No

Do you have high blood pressure(above 160/100), or have history of uncontrolled blood pressure (if you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery)

Yes No

Do you have blood pressure (below 90/70)? If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Yes No

Have you been advised to avoid strenuous exercise?

Yes No

Do you have any difficulty walking at a fast pace for 5 minutes?

Yes No

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

Yes No

Have you experienced any adverse reaction to any erectile dysfunction medication previously?

Yes No

Are you taking any medicines known as nitrates (often taken for chest pain/angina) or nitric oxide donors ('poppers')? (often taken for chest pain/angina Can be administered as a spray, tablet or patch. Include g.yceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate)

Yes No

Are you taking any of the following medications? - Any treatment for erectile dysfunction apart from Viagra (sildenafil), Levitra(vardenafil) or Cialis (tadalafil), Spedra(avanafil). - Medicinal nitrates such as glyceryle trinitrate, isosorbide mononitrate or isosorbide dinitrate and Nicorandil (including oral, transdermal and sublingual) - Recreational drugs prohibited by law (Class A, B or C). - Recreational nitrates such as amyl nitrate known as 'poppers' - Alpha blockers (used to treat high blood pressure or urinary symptoms associated with benign prostatic hyperplasia, and including tamsulosin, doxazocin, prazocin terazocin & indoramin). Medicines to treat high blood pressure - Warfarin - used to prevent heart attacks, strokes and blood clots. - Anti-virals including (Atazanavir, etravirine, fosamprenavir, indinavir, nelfinavir, ritonavir, saquinavir) - Anti-fungal medication such as Ketoconazole or itraconazole. -Quinidine/procainamide/amiodarone, Theophylline, Erythromycin/clarithromycin/cimetidine, phenobarbital, phenytoin and carbamazepine, (anticonvulsant medicines).

Yes No

Would you like to inform your GP of this consultation?

Yes No

How do you rate your confidence that you could get and keep an erection?(Required)

Very Low
Low
Moderate
High
Very High

When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?(Required)

No sexual activity
Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always or always

During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?(Required) 0

Did not attemt intercourse
Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always or always

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?(Required)

Did not attemt intercourse
Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult

When you attempted sexual intercourse, how often was it satisfactory for you?(Required)

Did not attemt intercourse
Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always or always