Question 1 of 11 0% Welcome to your private online men's clinic where you will be asked to answer some questions about your health to help us make an informed decision that the medication you are requesting is right for you. What biological sex were you assigned at birth?(Required) Male Female Are you currently:(Required) Pregnant Breastfeeding Not Applicable Please provide more information(Required) Do you currently have or have you had any medical problems or surgeries/operations, for example: Kidney problems, Hormone or sugar problems?(e.g. diabetes, thyroid problems), Neurological problems?(e.g. parkinsons, previous stroke or mini-stroke). Liver problems?(e.g. hepatitis, fatty liver, alcohol liver disease), Breathing problems?(e.g. asthma, COPD, bronchiectasis), Mental health problems?(e.g. anxiety, depression, personality disorder) or Thyroidectomy (removal of thyroid) Or any other diagnosed conditions.(Required) Yes No Please list all that apply to you(Required) Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.(Required) Yes No Use this space to list all medications you are on as well as the doses.(Required) Do you have any allergies to medications or any other substances?(Required) Yes No Use this space to list all medications and/or substances you are allergic to.(Required) Do you take or use any recreational drugs?(Required) Yes No Please list any recreational drugs you use. We need to know this information just in case any of the medications for this condition interact with the recreational drug you take(Required) Please select your blood pressure:(Required) Normal - 90/60 to 139/89 High - 140/90 or above Low - 90/60 or below Is there anything else you would like to include to allow our prescriber to prescribe responsibly?(Required) Yes No Please let us know of any other relevant medical or personal information by using the space below.(Required) What is your target weight? (stones/pounds/kg). Please ensure you update your current weight every time you re-order(Required) Please upload a maximum of 3 full length picture of yourself. These image(s) will only be visible to the medical professional providing the treatment We know it is inconvenient, however we request a photo for the safety of our patients and to prevent risks in those who are vulnerable **Optional Question - Please be aware, you can still proceed with the consultation without uploading a photo, it is not compulsory however it will help us in making an informed clinical decision**File Drop files here or Select files Accepted file types: jpg, jpeg, jfif, pjpeg, pjp, png, svg, tiff, Max. file size: 512 MB, Max. files: 3. If you have not used any medication to treat your ED before, our prescribers would advise you initially trial a small quantity at a low-dose. This is to check that you do not experience any adverse events or side effects. Most patients start on Sildenafil (Viagra) 50mg.Information to know about your ED treatment.(Required) You understand that you should never take a combination of different erectile dysfunction treatments at the same time (Sildenafil and Tadalafil within the same 24 hour period) You understand that you should seek immediate or emergency medical advice if you have a continuous erection for 4 hours or more. You confirm and understand that requesting treatment through our service does not guarantee a prescription if the treatment is unsuitable. In this instance, you will be refunded in full and signposted to another point of care. The decision about the treatment is for both patient and prescriber to consider; however, the final decision will always be with the prescriber. I understand consultationIDFileMax. file size: 512 MB.
