Medical Assessment

Are you male aged between 18-75?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you have trouble maintaining erection?

Yes No

Please tell us why do you require erectile dysfunction treatment?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you ever used or been prescribed any erectile dysfunction treatment?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Has your doctor advised that your are not fit enough for any physical and/or sexual activity?

Yes No

Can you provide more details please?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you feel very breathless or experience chest pain with light or moderate physical activity, such as walking briskly for 20 minutes or climbing two flights of stairs?

Yes No

Can you provide more details please?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you had a heart attack or stroke within the last 6 months?

Yes No

Can you provide more details please?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you have any other heart problems or are you under a doctor's care for any of the following?:

Yes No

Low blood pressure (below 90/50) or high blood pressure (above 150/90);
Unstable angina (chest pain), irregular heart beat or palpitations (arrhytmia);
A problem with one of the valves of your heart (valvular heart disease);
A problem where the heart muscle becomes inflamed and does not work as well as it should (cardiomyopathy);
Diabetes;
Heart problems causing blood flow issues (e.g. left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure;

Can you provide more details please?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking nitrates (nicorandil or other nitric oxide donors e.g. glyceryl trinirate (GTN spray), isosorbite mononitrate or isosorbite dinitrate) for chest pain?

Yes No

Please provide the name of the treatment.

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any of the following:

Yes No

Ritonavir (for HIV infections);
Any alpha blockers such as afluzosin, doxazosin, tamsulosin;
Drugs called poppers for recreational purposes e.g. amyl nitrate;
Riocigulat or other granylate cyclase stimulators for lung problems;
CYP3A4 inhibitors, e.g. saquinavir (to treat HIV), cimetidine (heartburn treatment), itraconazole or ketoconazole (to treat fungal infections), erythromycin or rifampicin (antibiotics) or diltiazem (for high blood pressure);

Please specify which of the medicine(s) above you are taking and their dosage

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any other medication not mentioned in the question above?

Yes No

Please provide the name, dosage and the reason why you are taking that medication or medications.

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you drink alcohol?

Yes No

We can still prescribe you this medication, however please note that smoking and drinking alcohol can make your erectile dysfunction condition worse.

Have you ever suffered from any of these conditions?

Yes No

Peyronie´s disease or any other deformation of the penis;
Loss of vision because of damage to the optic nerve ;
Galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption;
Been previously diagnosed with liver disease (including cirrhosis) or severe kidney impairment;
Sickle cell anaemia, multiple myeloma or leukemia;
Bleeding issues e.g. haemophilia or have active stomach ulcer;

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you agree to the following?

Yes No

You are aware that this medicine can lower your blood pressure increasing the risk of falls ;
You have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health;
You will inform your doctor about any unusual side effects;
The treatment is solely for your own use;
You will read the patient information leaflet supplied with your medication;
You will not exceed the maximum daily dose of this medication ;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

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I confirm that I am over 18 and I agree to the Terms and Conditions and the Privacy Policy.

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