Erectile Dysfunction

Are you aware of how high or low your blood pressure is?
This could be from an examination by your doctor, a certified medical practitioner or self-examination.

Yes

No

If you are aware of your blood pressure condition, do you check with your doctor regularly to ensure it is under control?

Yes

No

Can you relate to any of the following statements?
You have or have had stomach or duodenal ulcers, as well as stomach or intestinal bleeding in the past.
Your doctor has ever told you that your kidney function is less than 100 percent.
You have previously suffered a terrible reaction to aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs).
You want to use Ibuprofen Gel on skin that is fractured, injured, diseased, or infected.

Yes

No

Are you experiencing any of the following health issues?
You've had a heart procedure, a stroke, or a heart attack in the last five years.
You have angina, aortic stenosis, heart failure, cardiomyopathy, high blood pressure that is uncontrolled (greater than 160/90), arrhythmia, or severe heart disease.
You have suffered low blood pressure, fainting, or feeling dizzy when you stand up after lying down in the past.
Diabetes (type I or type 2) or blood sugar levels that are abnormal.
Medical diseases that impact the eyes, such as glaucoma or degenerative eye disease, as well as a family history of these conditions.
Peyronie's disease is a deformity or angulation of the penis.
Sickle cell disease, leukemia, or multiple myeloma are all examples of blood cancers.
A disease that causes bleeding

Yes

No

Do you have a history of using Cialis Once Daily before to treat ED?
If so, how successful was it?

Yes

No

Are you on any of the following medication?
Antibiotics.
Antihistamines such as stemizole or terfenadine.
Cisapride for stomach discomfort.
Quinidine for circulatory problems.
Pimozide for schizophrenia.

Yes

No

Did you know that:
A healthcare practitioner should assess any acute injuries.
You should see your doctor about chronic pain at least once a year.

Yes

No

Do you consent to seek medical help right away if you have any of the following symptoms:
An erection lasting more than 4 hours.
Vision is hazy.
One or both eyes have a sudden decline or loss of vision.
Pain in the chest.

Yes

No

What is your biological gender?
Please select your option

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

No

Can you relate to any of the following?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

No

Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.

Yes

No

Do you have a history of using Vitaros Cream to treat ED?
If so, how successful was it?

Yes

No

Are you aware that Vitaros will be sent in a cool pack that must be placed in the refrigerator as soon as possible after delivery?

Yes

No

Are you aware of the following:
It is never a good idea to self-diagnose and treat urine incontinence.
At the very least, you should see your doctor for a checkup once a year.
You must follow your doctor's instructions for any treatment.
You should only order repeat supplies of medicines that your doctor has prescribed.

Yes

No

If you have a history of using any ED medication, did you suffer any side effects?
If you did, kindly describe the effects

Yes

No

Have you tried any erectile dysfunction medication before?
You can select one or more options

Viagra

Cialis

Levitra

Spedra

I've never used any ED medication before.

Has a cerified medical practitioner examined you with erectile dysfunction?
Do you require assistance?

Yes

No

Have you ever been told that you have high or low blood pressure?
This may have been by your GP or another healthcare professional, or by taking your own blood pressure on a home monitor.

Yes

No

If you have tried ED treatments before, did you get any side effects? If yes, please let us know what you expreienced
Do you have an allergy to Sildenafil, Tadalafil or Vardenafil

Yes

No

Have you taken any ED treatments before?
Have you taken either Sildenafil, Tadalafil or Vardenafil

Yes

No

Have you been diagnosed with erectile dysfunction by a doctor?

Yes

No

Have you had a serious reaction to an ED medicine before?
If yes, please describe the product/reaction.

Yes

No

Do you have higher or lower than normal blood pressure?
If yes, please provide details

Yes

No

Have you been advised to avoid strenuous exercise?
If yes, please provide the reason

Yes

No

Do you have a medical history of the following:
Heart disease, heart attack, angina (chest pain during exertion), stroke, mini-stroke (transient ischaemic attack), sight loss due to poor circulation, inherited eye disease – retinitis pigmentosa, severe kidney or liver disease, deformity of the penis (e.g. Peryonie’s Disease), painful erections, sickle cell disease / leukaemia / multiple myeloma, bleeding conditions (e.g. haemophilia), stomach ulcers (e.g. gastric/peptic ulcer)

Yes

No

Is walking or running difficult for you?

Yes

No

Do you have symptoms of depression and have not seen a GP?
If yes, please provide details

Yes

No

Do you have difficulty in getting or maintaining an erection?

Yes

No

Do you have any recent or past medical history of note?
If yes, please provide details

Yes

No

Are you aware that erectile dysfunction can sometimes mask underlying medical conditions, so it is recommended that you agree to consult your doctor about this?

Yes

No

Do you take any current or repeat medicines?
If yes, please provide details

Yes

No

Please list all your current prescription medication including any medication you buy over the counter...

Please write below any further information which may be relevant e.g. medicines, conditions...

All Conditions

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