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Erectile Dysfunction

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at enquiries@thefamilychemist.co.uk

About You

1. Are you purchasing this medication for yourself?
2. Are you over 18 years old?

3. Do you smoke?

Reducing or stopping smoking can help reduce the symptoms of erectile dysfunction.

4. Do you drink alcohol?

Excessive drinking can cause erectile dysfunction.

5. Are you overweight?

Being overweight may cause symptoms of erectile dysfunction, increasing exercise and losing weight can help reduce ED.

Medical History

6. Do you have difficulty getting and/or maintaining an erection?

7. Have you ever been told by your doctor to avoid physical and/or sexual activity

8. Do you suffer from or ever suffered from any of the following?

  • Low blood pressure or uncontrolled high blood pressure
  • heart attack or stroke within the last 6 months
  • 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 obstructions, aortic narrowing) or severe cardiac failure.
  • Any other heart conditions

Please provide more details:

9. Do you suffer from any of the following conditions?

  • A deformity to the penis such as Peyronie’s Disease
  • Loss of vision due to non-arteritic anterior ischaemic optic neuropathy (NAION) or have an inherited eye disease (such as retinitis pigmentosa)
  • Galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption.
  • Previously diagnosed liver disease (including cirrhosis of the liver) or severe kidney disease/impairment.
  • Sickle cell anaemia, multiple myeloma or leukaemia.
  • Any bleeding issues (e.g. haemophilia) or have active stomach ulcers.

Please Let us know what treatments you have tried:

10. Do you take any of the following medication?

  • Alpha Blockers (Doxazosin, Alfuzosin, Prazosin, Tamsulosin, Indoramin or Terazosin)
  • HIV Protease Inhibitors (Atazanavir, darunavir, fosamprenavir, lopinavir, ritonavir, saquinavir, tipranavir)
  • Antifungals (Itraconazole, Ketoconazole, Isavucanazole, posacanzole or Voriconazole)
  • Antiepileptics (Carbemazepine, Fosphenytoin, Phenobarbitol, Phenytoin, Primidone)
  • Calcium Channel Blocker (diltiazam or verapamil)
  • Netupitant, Nicorandil,Imatinib, Idelalisib, Enazlutamide, Crizotinib, Cobistat, Arpitant, Dronaderone, Nicorandil, Nilotinib, Rifampicin, Riociguat.

Please provide more details:

11. Have you tried any treatments for Erectile Dysfunction Before?

Please let us know what treatments you have tried:

Past Medical History

12. Do you have any kidney or liver impairment?

Please provide more details:

13. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

Please provide more details:

14. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

Please provide more details:

15. Are you allergic to any medicines or other substances e.g. peanuts or soya?

Please provide more details:

16. Would you like us to pass on details of your treatment to your GP?

17. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at enquiries@thefamilychemist.co.uk so we can talk through your options.

  • You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
  • You have answered the questions honestly and accurately and the treatment is solely for your personal use.
  • You will read and understand the patient information leaflet supplied with your medication.
  • You understand that although it is not compulsory it is important to inform your GP of this treatment so they can provide safe healthcare.
  • You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
  • You are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
  • You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

I confirm that I have read the information in this questionnaire and will follow the advice shown here and in the product leaflet

Please click "Yes".