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Patient notice! This questionnaire forms the basis of your erectile dysfunction consultation today. We need you to be honest with your answers including any current medication you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medicinal information provided before selecting your treatment.

If you require a particular manufacturer of medication, please contact us after placing your order.

1
Your Erectile Dysfunction

Are you male and aged between 18-70?

NoYes

Sorry, based on your response we cannot offer treatment. Please see your GP or a specialist regarding your condition.

Please enter your date of birth

Do you persistently have difficulty getting and maintaining an erection? *

NoYes

Please provide more information below.

Note: If your ED symptoms are only occassional, you may find that counselling may help. You can discuss options with your GP.

2Your Health

Are you taking Nicorandil or any nitrate medication? This includes any sprays, patches, gels or creams. Warning: there can be a fatal reaction between ED medication and these medications. *

NoYes

Sorry, based on your response we cannot offer treatment. Please see your GP or a specialist regarding your condition.

Are you taking any prescription medication? *

NoYes

Are you taking any of the following prescription medicines?

Flomax
Tamsulosin
Alfuzosin
Doxazosin
Terazosin
Any other alpha-blockers used for high blood pressure or prostate issues
Any diuretics or water used for high blood pressure, heart and kidney problems
Any beta-blockers used for heart conditions: high blood pressure, anxiety etc

NoYes

Please provide more information below. *

Please list any other prescription medicines you are taking. *

If taking heart medication, has your GP has assessed your cardiovascular risk? If you are not taking any heart medication, please answer yes. *

NoYes

Are you circumcised? *

NoYes

Do you have trouble retracting your foreskin fully when your penis is erect? *

NoYes

Please provide more information below. *

Do you suffer from angina, aortic stenosis, hypertrophic obstructive cardiomyopathy, uncontrolled blood pressure, arrhythmia, or severe heart disease? *

NoYes

Please provide more information below. *

Have you had a heart operation, heart attack or a stroke in the last six months? *

NoYes

Sorry, based on your response we cannot offer treatment. Please see your GP or a specialist regarding your condition.

Do you suffer from low blood pressure, faints or collapses? Low blood pressure is less than 90 / 50. If you are unsure, check with your GP or local pharmacy. *

NoYes

Sorry, based on your response we cannot offer treatment. Please see your GP or a specialist regarding your condition.

Do you suffer from high blood pressure? High blood pressure is higher than 160 / 90. If you are unsure, check with your GP or local pharmacy. *

NoYes

Please provide more information below. *

Have you been advised to avoid strenuous exercise, or do you have difficulty in walking for more than 5 minutes at a fast pace? *

NoYes

Sorry, based on your response we cannot offer treatment. Please see your GP or a specialist regarding your condition.

Have you ever had any problems with your kidneys, urinary system or with your liver? *

NoYes

Please provide more information below. *

Do you have any eye problems, such as hereditary degenerative retinal disorders or macular degeneration? *

NoYes

Sorry, based on your response we cannot offer treatment. Please see your GP or a specialist regarding your condition.

Have you ever been diagnosed with diabetes or abnormal blood sugar levels? *

NoYes

Please provide more information below. *

Do you have any known allergies? *

NoYes

Please provide more information below.

Calculate your BMI here

Is your BMI under 30? Use the above BMI calculator to find out.

Confirm

Do you smoke? *

Please read about NHS help available to stop smoking. We also offer a stop smoking service via our online doctor.

Do you often drink more than 21 units of alcohol per week? *

NoYes

Please provide more information below.

Please read about NHS help available to help with reducing alcohol consumption here

3
Consent

Are you aware you should not take any combination of ED medications at the same time? *

Confirm

Note: we are unable to issue more than 8 tablets of a second ED medication when you are placing an order for more than 8 tablets of another ED medication. Placing an order for more than this quantity will delay your order as we will need to contact you to determine your preference and amend your order.

I understand if I have a continuous erection for 4 hours or more I should seek immediate medical advice?

Confirm

We strongly advise that you inform your GP of any medication you receive.

Would you like us to inform your GP of medication you receive from Rightdose?

It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.

Please provide further details below so we can inform your GP on your behalf.

Please enter your:

Full Name
Date of Birth
Your registered home address with your GP

Please enter your:

GP Surgery Name
GP Surgery Address
GP Surgery Email
GP Surgery Contact Number

I confirm:

I am over 18 years old.
The medicine ordered is for my sole use only.
I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
I have answered all the questions truthfully.
I agree to the Rightdose online pharmacy privacy policy and terms and conditions.

Confirm

If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

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