Medical History

Please answer the following questions about your medical history.

Do you have any of the following conditions affecting your penis? *

Anatomical deformation (eg angulation, curvature, cavernosal fibrosis, peyronies)
History of recurrent priapism or conditions which predispose to it (prolonged erection of the penis)
Sickle cell anaemia, multiple myeloma, leukaemia, thrombocythemia or polycythaemia
Painful erections or penile implants
Balanitis
Acute or chronic urethritis
Hypospadias

YesNo

Do you suffer from any of the following conditions? *

Angina
Congestive heart failure (Class 2 or greater)
Uncontrolled arrhythmias (irregular or abnormal heart beats)
Aortic stenosis
Hypertrophic obstructive cardiomyopathy
Postural hypotension
Syncope (fainting episodes)
Bleeding / blood clotting disorders
Unstable heart conditions

YesNo

Have you suffered from any of the following events in the last 6 months? *

Heart Attack
Stroke
Mini stroke (TIA)
Life threatening arrhythmia (irregular heart beat)

YesNo

Blood pressure confirmation *

You should have your blood pressure checked before taking this medication. If your blood pressure is more than 170/100mmHg or less than 90/50mmHg, this medication is not suitable for you. You can have this checked at your GP or your local pharmacy. Please tick to confirm that you will have your blood pressure taken, and you will check you are within this range, before taking the medication.

I agree

Have you been advised by a doctor to avoid sexual activity or strenuous exercise due to the health of your heart? *

YesNo

Do you have any of the following conditions? *

Weakened liver
Weakened kidney function
Active stomach ulcer
Any history of gastric disorders

YesNo

Do you have any of the following problems with your eyes? *

Sudden loss of vision in one eye
Non-arteritic anterior ischemic optic neuropathy (NAION)
Any hereditary retinal degenerative disorder

YesNo

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Important

These questions help us identify if Sildenafil is safe for you or if you need to see a GP.

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Medication Safety

Please answer honestly so our clinicians can assess suitability.

GPhC Registered

NPA Member