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Intro

Medical

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Please fill in the erectile dysfunction consultation below

Are you 18 years of age or older?

Yes

Are you completing this form for yourself?

Yes

What is your main reason for requesting treatment today?

Difficulty getting an erection

Difficulty maintaining an erection

Both

Other

Have you ever been advised to avoid sexual activity for medical reasons?

Yes

In the last 6 months, have you experienced any of the following?

Heart attack

Stroke

Neither

Do you get chest pain, pressure, or discomfort when you exert yourself?

Yes

Do you have any ongoing heart or circulation problems that are not well controlled?

Yes

Not Sure

Do you often feel faint, dizzy, or have very low blood pressure readings?

Yes

Have you ever been diagnosed with any of the following?

Have you ever had sudden or unexplained loss of vision?

Yes

Do you have any structural or anatomical condition affecting the penis (for example curvature or scarring)?

Yes

Are you currently taking any medicines (prescribed or purchased)?

Yes

Are you taking any of the following?

If you selected any medicines above or take regular treatment, please list them:

Do you smoke cigarettes or use nicotine products?

Yes

Do you drink alcohol?

Yes

How often per week?

Do you use recreational or non-prescribed drugs?

Yes

How long have you been experiencing erection difficulties?

Recently (less than 3 months)

A few months (3–6 months)

Long-term (more than 6 months)

Have you used sildenafil, Viagra, or similar treatments before?

Yes

How did it work for you?

Do you identify as male?

Yes

Are you requesting treatment for erectile dysfunction (difficulty getting or maintaining an erection)?

Yes

Have you ever been told by a healthcare professional to avoid sexual activity due to a heart condition?

Yes

Have you had a heart attack in the last 6 months?

Yes

Have you had a stroke in the last 6 months?

Yes

Do you experience chest pain during physical activity or sexual activity?

Yes

Do you have uncontrolled high blood pressure?

Yes

Do you have low blood pressure or feel dizzy when standing?

Yes

Have you ever had sudden loss of vision in one or both eyes?

Yes

Do you have any condition affecting the shape of your penis (e.g. Peyronie’s disease)?

Yes

Are you currently taking any prescription or over-the-counter medicines?

Yes

Are you taking nitrate medicines for chest pain (e.g. GTN spray, isosorbide mononitrate/dinitrate)?

Yes

Are you taking riociguat (for pulmonary hypertension)?

Yes

Are you taking alpha-blockers for prostate or blood pressure?

Yes

Please provide details

Have you used Viagra or sildenafil before?

Yes

Did it work for you?

Final Declaration

I confirm that the information provided is accurate to the best of my knowledge
I understand that this medicine is not suitable for everyone
I agree that my answers will be reviewed by a healthcare professional
I understand that treatment may be refused if it is not clinically appropriate

I confirm that I understand and agree to the above

Consent

I confirm that the information I have provided is true and complete
I understand Viagra may not be suitable for everyone
I understand my answers will be reviewed by a healthcare professional
I consent to treatment review and clinical decision-making based on this information

I confirm that I understand and agree to the above

Based on the details you provided, we cannot safely prescribe weight loss medication for you. We recommend asking your GP for advice about losing weight.

Annie



The pharmacist was amazing. He helped answer all my questions regarding weight loss injections. He took my blood pressure made sure everything was perfect. Answered questions I need to know definitely return felt confident in his knowledge

John Williamson



The consultant was good and had the information I was looking for and I am going to enjoy trying this treatment to see if it helps me to lose weight thanks.

Lynda



Reassuring start to my weight loss journey. Given appointment quickly, and reassuring that a couple of things were checked with GP. Everything explained clearly, and my questions answered. I was assured that I should be in touch with pharmacist if there were any problems.

Danny Rawlings



Very professional, helpful, and reassuring Would recommend to anybody looking to purchase weight loss medication.

Anthony



My weight loss journey The pharmacist was very helpful and went into detail regarding the weight loss treatment, explaining any possible side effects that may happen.

Mr Keith Allan



Weigh loss management we had a lot of questions,and answers were provided, made us feel at ease and ensured that we were happy to go a head with the weight loss plan, We felt that any other issues we have we can contact them any time.

FeeP



A thoroughly positive experience My weight loss consultation was a thoroughly positive experience. From the very first phone conversation to the end of the introductory consultation, Jane gave me all the relevant information and really listened to my questions and concerns.

Charles Terry



Sai was very understanding of my situation and reasons for taking advantage of the weight loss programme. He explained clearly what was involved and gave additional support in terms of the diet I should try to follow.

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07344 110940
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