Consultation - Menschem

Are you purchasing this medication for yourself?

YesNo

Are you over 18?

YesNo

Please select which statement best suits your erectile dysfunction symptoms:

Difficulty getting an erectionDifficulty maintaining an erectionBoth - Difficulty getting and maintaining an erectionI do not have erectile dysfunction

Have you tried any treatments for Erectile Dysfunction Before?

YesNo

Please specify

Have you been instructed by your doctor to avoid sexual or physical activity?

YesNo

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

YesNo

Do you suffer from or ever suffered from any of the following?

Low blood pressure or uncontrolled high blood pressure
Severe cardiac disorders such as unstable angina and severe cardiac failure
Left ventricular outflow obstruction (e.g., aortic stenosis, hypertrophic obstructive cardiomyopathy or idiopathic hypertrophic subaortic stenosis)
Exercise-induced ventricular tachycardia, implanted internal cardioverter defibrillator with frequent shocks, and poorly controlled atrial fibrillation
Aortic and mitral valve disease, pericardial constriction, restrictive or congestive cardiomyopathy, significant left ventricular dysfunction, symptomatic coronary artery disease, Pulmonary veno-occlusive disease
Heart failure

YesNo

Please specify

Do you have any other heart conditions?

YesNo

Please specify

Do you have a hereditary intolerance to galactose, lapp lactase deficiency or glucose-galactose malabsorption.

YesNo

Do you have any allergies?

YesNo

Please specify

Do you suffer from any of the following medical conditions?

Previously diagnosed severe kidney disease, impairment or if you have been told your eGFR < 30mL/minute/1.73m2
Previously diagnosed liver disease or impairment
Sickle Cell Anaemia, Leukaemia or Multiple Myeloma
An active stomach ulcer (if it is not active then tick no)
A deformity to the penis such as Peyronie’s Disease
Loss of vision due to non-arteritic anterior ischaemic optic neuropathy (NAION) as known hereditary degenerative retinal disorders
Allergy, intolerance or hypersensitivity to sildenafil, tadalafil, vardenafil or avanafil.

YesNo

Please specify

Do you take any other medication or have any other medical conditions?

YesNo

Please list all medications you take and medical conditions you have

Do you take any of the following medication?

Alpha Blockers (Doxazosin, Alfuzosin, Prazosin, Tamsulosin, Indoramin or Terazosin)
HIV Protease Inhibitors (Atazanavir, darunavir, fosamprenavir, lopinavir, ritonavir, saquinavir, tipranavir, atazanavir, clarithromycin, nefazodone, nelfinavir, telithromycin)
Antifungals (Itraconazole, Ketoconazole, Isavucanazole, posacanzole or Voriconazole)
Antiepileptics (Carbemazepine, Fosphenytoin, Phenobarbitol, Phenytoin, Primidone)
Calcium Channel Blocker (diltiazam or verapamil)
Netupitant, Imatinib, Idelalisib, Enazlutamide, Crizotinib, Cobistat, Arpitant, Dronaderone, Nilotinib, Rifampicin, Riociguat
Any medication or drugs known to prolong the QT interval such as antidepressants (i.e. amitriptyline, citalopram/escitalopram, clomipramine, dosulepin, doxepin, imipramine, lofepramine), antiarrhythmics (ie. Quinidine, disopyramide, procainamide, amiodarone, sotalol, flecainide) antipsychotics (i.e. risperidone, haloperidol, chlorpromazine, quetiapine, clozapine), antimicrobials (i.e. erythromycin, clarithromycin, moxifloxacin, fluconazole, ketoconazole) antiemetics (domperidone, ondansetron).

YesNo

Please specify

Do you take any nitrates, including amyl nitrate (poppers), or nitric acid donors such as nicorandil, glyceryl trinitrate, isosorbide mononitrate and isosorbide dinitrate?

YesNo

Do you take any recreational drugs?

YesNo

Please specify

Do you smoke?

YesNo

Do you drink alcohol?

YesNo

Are you overweight?

YesNo

I will read the patient information leaflet before using any provided treatments.

Yes

I agree that

All questions have been answered to the best of my knowledge.
I understand that I should regularly have my blood pressure, glucose and cholesterol levels checked with my GP.
I am happy for pharmacists to review my consultation and prescribe the item requested if it is clinically suitable for myself.
I understand my treatment request may be rejected due to clinical or other reasons.
The treatment is solely for my own use and not for the use of others.
I consent for SPK Pharma Ltd to undertake an ID check to confirm my age and identity. (This will be done using a credit check agency, no record will be put on your credit rating).
If you have used the requested medication before, you confirm it is working as intended.

Yes

I understand that Menschem will not inform my GP of this consultation, unless specifically requested via emailing info@menschem.co.uk (please include GP name, address, and email address).

Yes

Erectile Dysfunction Consultation