Pharmacy Medicine Questionnaire

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By law, our pharmacist is required to ask for some more information from you before supplying certain medicines in the UK, just like the one you have just purchased. This is much like a doctor is required to conduct a diagnosis before prescribing any medication. Please be kind enough to answer the following medical questions so that we can get your item shipped out to you as soon as possible.

Your order will not be shipped without full completion and approval of this form

Rest assured that your responses are kept highly confidential and will not be shared with anyone outside of our company. These questions are a legal requirement for us to supply you the medication purchased. Patient safety is important to us and hence we need these questions answered so that our pharmacists can authorise your orders despatch - without which we would not be able to proceed. We look forward to receiving your response and thank you for your understanding.

Thank you for shopping with us.

If you would rather call and talk to us about these questions, you can call us on

0116 326 4273

(Mon-Fri 9 am-5:00 pm)
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Full Name* This field is required.
First Name
Last Name
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E-mail* This field is required.
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Please enter your order ID* This field is required.
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Quantity Purchased
2 Tablets
4 Tablets
8 Tablets
Other
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Who is the intended user of this medication?* This field is required.Please state full name and your relationship to that person if not yourself.
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How old is the intended user?* This field is required.
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Have you used this medicaiton before? If yes, please state when* This field is required.
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Has your doctor advised that you are not fit enough for any physical and/or sexual activity?
YESNO
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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?
YESNO
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Do you have any other heart problems or are you under a doctor’s care for any of the following:• Low blood pressure or uncontrolled high blood pressure • Unstable angina (chest pain), irregular heart beat or palpitations (arrhythmia) • A problem with one of the valves in your heart (valvular heart disease) • A problem where the heart muscle becomes inflamed and does not work as well as it should (cardiomyopathy) • Heart problems causing blood flow issues (e.g. left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure
YESNO
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Are you taking nitrates (nicorandil or other nitric oxide donors e.g. glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate) for chest pain?
YESNO
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Are you using drugs called ‘poppers’ for recreational purposes (e.g. amyl nitrite)?
YESNO
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Are you taking ritonavir (for HIV infection)?
YESNO
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Are you taking any CYP3A4 inhibitors, e.g. saquinavir (to treat HIV infection), cimetidine (a heartburn treatment), itraconazole or ketoconazole (to treat fungal infections), erythromycin (antibiotic) or diltiazem (for high blood pressure)?
YESNO
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Are you taking any alpha-blockers, such as alfuzosin, doxazosin or tamsulosin, which are medicines to treat urinary problems due to enlarged prostate (benign prostatic hyperplasia) or occasionally to treat high blood pressure?
YESNO
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Do you have Peyronie’s disease or any other deformation of the penis?
YESNO
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Have ever had loss of vision because of damage to the optic nerve (such as non-arteritic anterior ischaemic optic neuropathy [NAION]) or have an inherited eye disease (such as retinitis pigmentosa)?
YESNO
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Do you have galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption?
YESNO
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Do you have previously diagnosed hepatic (liver) disease (including cirrhosis of the liver) or severe renal (kidney) impairment?
YESNO
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Do you have any of the following: sickle cell anaemia, multiple myeloma or leukaemia?
YESNO
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Do you have any bleeding issues (e.g. haemophilia) or have active stomach ulcers?
YESNO
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Do you have any further medical conditions?* This field is required.
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Viagra Connect

Viagra Connect is only intended for men aged 18 years and older who have erectile dysfunction (ED). Men who do not have ED will not benefit from using this product.

How to take Viagra Connect

Take one tablet approximately 1 hour before planning to have sexual intercourse. Viagra Connect can start to work within 30 minutes.

Take with or without food, but Viagra Connect may take longer to work after a high-fat meal.

Do not take with grapefruit or grapefruit juice, as it may modestly increase plasma levels of sildenafil.

The maximum recommended dosing frequency is one 50 mg tablet per day.

They may need to take Viagra Connect a number of times on different occasions (a maximum of one 50 mg tablet per day), before they can achieve a penile erection satisfactory for sexual activity. If, after several attempts (up to a maximum of 8 times) on different dosing occasions, patients are still not able to achieve a penile erection sufficient for satisfactory sexual activity, they should be advised to consult a doctor.

Medicines containing any nitrates (e.g. glyceryl trinitrate, isosorbide mononitrate, isosorbide dinitrate, amyl nitrite also known as ‘poppers’), or nitric oxide donors (e.g. sodium nitroprusside or nicorandil), must NOT be used at the same time as Viagra Connect as this combination may lead to a dangerous fall in blood pressure.

Men should tell their doctor that they have started taking Viagra Connect, especially if they are started on any new medicines.

Remind patients about common side effects. These include: headache, flushing, dyspepsia, nasal congestion, dizziness, nausea, visual disturbance, cyanopsia (blue-tinted vision) and blurred vision. Note: If any of these become a concern, talk with a pharmacist or doctor.

Serious Side Effects

Men should be advised to STOP TAKING Viagra Connect and seek medical attention IMMEDIATELY if they experience any of the following SERIOUS side effects. Side effects can be reported by patients or pharmacists via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard.

Chest pains: If this occurs before, during or after intercourse, they should get into a semi-sitting position and try to relax. Nitrates must NOT be used to treat chest pains.

A persistent and sometimes painful erection lasting longer than 4 hours.

A sudden decrease or loss of vision.

An allergic reaction. Symptoms include sudden wheeziness, difficulty breathing or dizziness, swelling of the eyelids, face, lips or throat.

Serious skin reactions such as Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Syndrome (TEN). Symptoms may include severe peeling and swelling of the skin, blistering of the mouth, genitals and around the eyes, fever.

Seizures or fits.
Should be Empty:

Viagra Connect

How to take Viagra Connect

Serious Side Effects