| What is your date of birth? | |
| What is your height? | |
| What is your weight? | |
| What is your blood pressure? | |
| Are you male? | |
| |
| Has this medication been previously prescribed to you by your GP? | |
| |
| Do you have trouble achieving or maintaining your erection? | |
| |
| Cardiovascular health- Do any of the following apply to you Has your doctor advised that you are not fit enough for any physical, or sexual activity.
Do you have difficulty with light/moderate excercise, such as a brisk walk for 5 mins.
Low blood pressure (below 90/50) or uncontrolled high blood pressure (150/90)
unstable angina, irregular heart beat or palpitations
Heart attack or stroke within the last six months
any other heart or heart valve problems | |
| |
| Please tell us about any other medical conditions you are diagnosed with or if you take any other prescribed medication, over the counter medication or recreational products? Please enter N/A if not applicable. | |
| |
| Have you ever suffered from any of the conditions listed below? Loss of vision because of damage to the optic nerve to optic nerve (such as non-arteritic anterior ischemic optic neuropathy or inherited eye disese).
Active stomach ulcers (Also known as peptic/gastric ulcer) or bleeding issues
Liver or kidney problems
Overactive thyroid gland
Any deformation of the penis, such as angulation or Peyronie \’s disease
An erection that lasted more than 4 hours
sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood cells), multiple myeloma (cancer of bone marrow)
Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption | |
| |
