About your condition and treatment
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
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Are you aware of how high or low your blood pressure is?
This could be from an examination by your doctor, a certified medical practitioner or self-examination.
If you are aware of your blood pressure condition, do you check with your doctor regularly to ensure it is under control?
Can you relate to any of the following statements?
You have or have had stomach or duodenal ulcers, as well as stomach or intestinal bleeding in the past.
Are you experiencing any of the following health issues?
You've had a heart procedure, a stroke, or a heart attack in the last five years.
Do you have a history of using Cialis Once Daily before to treat ED?
If so, how successful was it?
Are you on any of the following medication?
Antibiotics.
Did you know that:
A healthcare practitioner should assess any acute injuries.
Do you consent to seek medical help right away if you have any of the following symptoms:
An erection lasting more than 4 hours.
What is your biological gender?
Please select your option
If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option
Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.
Do you suffer from any allergies?
If you do, kindly explain them below
Can you relate to any of the following?
You have an underlying medical condition
Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.
Do you have a history of using Vitaros Cream to treat ED?
If so, how successful was it?
Are you aware that Vitaros will be sent in a cool pack that must be placed in the refrigerator as soon as possible after delivery?
Are you aware of the following:
It is never a good idea to self-diagnose and treat urine incontinence.
If you have a history of using any ED medication, did you suffer any side effects?
If you did, kindly describe the effects
Have you tried any erectile dysfunction medication before?
You can select one or more options
Has a cerified medical practitioner examined you with erectile dysfunction?
Do you require assistance?
Have you ever been told that you have high or low blood pressure?
This may have been by your GP or another healthcare professional, or by taking your own blood pressure on a home monitor.
If you have tried ED treatments before, did you get any side effects? If yes, please let us know what you expreienced
Do you have an allergy to Sildenafil, Tadalafil or Vardenafil
Have you taken any ED treatments before?
Have you taken either Sildenafil, Tadalafil or Vardenafil
Have you been diagnosed with erectile dysfunction by a doctor?
Have you had a serious reaction to an ED medicine before?
If yes, please describe the product/reaction.
Do you have higher or lower than normal blood pressure?
If yes, please provide details
Have you been advised to avoid strenuous exercise?
If yes, please provide the reason
Do you have a medical history of the following:
Heart disease, heart attack, angina (chest pain during exertion), stroke, mini-stroke (transient ischaemic attack), sight loss due to poor circulation, inherited eye disease – retinitis pigmentosa, severe kidney or liver disease, deformity of the penis (e.g. Peryonie’s Disease), painful erections, sickle cell disease / leukaemia / multiple myeloma, bleeding conditions (e.g. haemophilia), stomach ulcers (e.g. gastric/peptic ulcer)
Is walking or running difficult for you?
Do you have symptoms of depression and have not seen a GP?
If yes, please provide details
Do you have difficulty in getting or maintaining an erection?
Do you have any recent or past medical history of note?
If yes, please provide details
Are you aware that erectile dysfunction can sometimes mask underlying medical conditions, so it is recommended that you agree to consult your doctor about this?
Do you take any current or repeat medicines?
If yes, please provide details
Please list all your current prescription medication including any medication you buy over the counter...
Please write below any further information which may be relevant e.g. medicines, conditions...
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