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Health Questions
Please answer the following questions to help us assess your suitability for treatment.
What is your biological sex from birth?
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Male
Female
Do you have difficulty achieving an erection or maintaining an erection?
*
Yes
No
Are you taking any nitrate medications such as glyceryl trinitrate (GTN) spray, tablets, patches or ointment; isosorbide mononitrate; isosorbide dinitrate; nicorandil or recreational amyl nitrate ('poppers')?
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Yes
No
Are you taking medicines called Alpha-blockers (eg alfuzosin, prazosin, doxazosin, tamsulosin) which are normally used for blood pressure or prostate problems?
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Yes
No
Are you taking any of the following medications?
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CYP3A4 inhibitors (ritonavir, saquinavir, indinavir, atazanavir, itraconazole, ketoconazole, clarithromycin, erythromycin, cimetidine and grapefruit juice)
Sacubitril/valsartan (brand Entresto)
Riociguat
QT prolonging drugs (quinidine, procainamide, amiodarone and sotalol)
Yes
No
Are you taking 5-alpha-reductase inhibitors (for example Finasteride or Dutasteride) for hair loss?
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Yes
No
Apart from those already declared, do you take any other prescription, non-prescription or recreational medication?
*
Yes
No
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