Sexual Health

1

Full Name* This field is required.

First Name

Last Name

2

Email Address* This field is required.

example@example.com

3

Phone Number* This field is required.

4

Date of Birth* This field is required.

Date

5

Are you male and aged between 18-75?* This field is required.

Yes

No

6

Do you smoke or drink?* This field is required.

Yes

No

7

Have you taken Viagra (sildenafil), Levitra (vardenafil), Nipatra, Spedra or Cialis (tadalafil) at least 4 times previously without any side effects?* This field is required.

Yes

No

8

Do you have trouble achieving or maintaining your erection?* This field is required.

Yes

No

9

In the past 6 months, how often do you have difficulty getting and/or sustaining an erection during sexual activity?* This field is required.

Always

Often

Occasionally

10

Do you have high blood pressure (above 160/90), or are you currently on treatment for high blood pressure?* This field is required.If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Yes

No

11

Do you have low blood pressure (below 90/50)?* This field is required.If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Yes

No

12

Have you been advised to avoid strenuous exercise?* This field is required.

Yes

No

13

Would you have any difficulty walking at a fast pace for 5 minutes?* This field is required.

Yes

No

14

Do you suffer from depression for which you have not seen a GP?* This field is required.

Yes

No

15

Do you have any allergy to Viagra (sildenafil), Levitra (vardenafil), Spedra (avanafil) or Cialis (tadalafil) or have you experienced any adverse reaction to any erectile dysfunction medication previously?* This field is required.

Yes

No

16

Declaration & Consent* This field is required.

I understand that these products are not a substitute for medical diagnosis or treatment.

I confirm that the information I have provided is accurate and complete.

17

Appointment* This field is required.