Male Patients Form

Put your details

Pharmacy Name* Pharmacy Location* Pharmacy EirCode*

Which medication are you looking to get a prescription for? Choose... VIAGRA CIALIS LEVITRA SPEDRA SILDENAFIL CLONMEL (GENERIC VIAGRA) SIDENA (GENERIC VIAGRA) If other, please specify:

Please indicate what dose for the list below, if you are unsure, please select 'Don't Know' Choose... DON'T KNOW 2.5 MG 5 MG 10 MG 20 MG 25 MG 50 MG 100 MG If other, please specify:

Do you have any allergies that you know of?

Have you used your requested ED treatment previously?

What age are you?

Have you been prescribed a medication for ED by your GP previously?

When was your blood pressure taken last? Choose... IN THE LAST 6 MONTHS MORE THAN 6 MONTHS AGO NEVER

Apart from conditions already mentioned in this form, do you suffer from any other medical conditions or have you had any surgical procedures in the past that you feel our Doctors should be aware of?

When did you first become aware of your ED?

Is your ED problem getting noticeably worse or is it staying same?

Did your ED present gradually or did it develop all of a sudden?

You last had sexual intercourse?

In regards to describing your last erection, would you regard it as fully stiff or was it soft?

During your last sexual intercourse was your erection sufficient enough for you to manage penetration of your partner?

Was your erection sustained so that you were able to climax?

During sexual intercourse, does your erection go soft and inhibit your ability to penetrate your partner?

How often would you have a morning erection (notice an erection upon wakening)? Choose... MOST MORNINGS 1-2 PER WEEK 1-2 PER MONTH LESS FREQUENTLY NOT ANY MORE If other, please specify:

Are you able to ejaculate when you masturbate?

During periods of masturbation, would your penis's erection be hard or soft?

Did you ever receive a diagnosis or treatment for any psychological issues (such as anxiety, panic attacks or reactive depression), or for any psychiatric issues (such as, mania, bipolar disorder or schizophrenia)?

Do you find that your ED impacts your relationship?

Do you exercise on a regular basis?

Are you currently a smoker? Choose... NO, I DO NOT SMOKE YES, I DO UNDER 5 A WEEK YES, I DO UNDER 10 A WEEK YES, I DO LESS THAN 5 A DAY YES, I DO LESS THAN 10 A DAY YES, I DO LESS THAN 15 A DAY YES, I DO LESS THAN 20 A DAY YES, I DO MORE THAN 20 A DAY

Do you drink alcohol (1 unit = 125ml wine, ½ pint beer, bar measure of spirits)? Choose... NO, I DO NOT SMOKE YES, I DO UNDER 5 A WEEK YES, I DO UNDER 10 A WEEK YES, I DO LESS THAN 5 A DAY YES, I DO LESS THAN 10 A DAY YES, I DO LESS THAN 15 A DAY YES, I DO LESS THAN 20 A DAY YES, I DO MORE THAN 20 A DAY

Do you currently take any prescription medications?

Do you currently take any non-prescribed or herbal medication?

Do you currently take any recreational/illegal drugs?

Gender

What height are you? (enter as centimeters)

What weight are you? (enter as kg)

The prescription is digitally sent to a pharmacy of your choosing (place Pharmacy details below eg: Stacks Pharmacy / Bettystown)

I confirm that I fully understand and have read completely all questions in this form and all of my answers are true and accurate, to the best of my knowledge.

I confirm that I am not seriously unwell and I do NOT have any of the following symptoms: chest pain, shortness of breath, unable to swallow fluids or saliva, weakness or numbness down one side of my face or limbs or body, slurred speech. I confirm I do not think I need to see a GP. I confirm that this is not a replacement for a doctor's visit. I have read, understood and agree with the information in the terms of service and consent to the use of information in accordance with the (privacy policy).