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2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3049 6500
Fax. 020 3049 6515
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Erectile Dysfunction Online Consultation

Please fill out the form below, and one of our doctors will contact you regarding the consultation:

Patient Information

Name: *
Date Of Birth: *
NHS Number (if known):
Address:
Postcode:
Contact Number: *
E-Mail Address: *

Consultation Information

1. Have you read information about your symptoms on Patient.info?

    It is advised that you read up about this condition and the related symptoms.

    Yes

    No

    2. Do you sometimes or always have difficulty getting and keeping an erection?

      We can not provide a treatment if you do not have erectile dysfunction.

      Yes

      No

      3. Have you had difficulties with erections for more than a year?

        Yes

        No

        4. Are your erections sometimes fine?

        • E.g. when waking in the morning, during masturbation or in some erotic situations

        Yes

        No

        5. Is your blood pressure high (Over 160/90)

        • You must have had a blood pressure check within the last year and know the result. Doctors, nurses and some pharmacist can check blood pressure. Answer 'Yes' if either figure is high, 160 or 90. A blood pressure measurement whilst taking blood pressure tablets qualifies.
        Please consult your regular doctor before taking tablets for erectile dysfunction. We are unable to prescribe tablets for you.

        Yes

        No

        Don't Know

        6. Do you have low blood pressure?

        • This means any of the following:
        • Low blood pressure requiring investigation
        • Low blood pressure requiring treatment
        • Being prone to faint or feel light-headed for more than a few seconds when standing up quickly or standing for long periods
        We are not able to supply treatment. ED medication may cause a drop in blood pressure. Please discuss with your GP whether erectile dysfunction medication would be suitable.

        Yes

        No

        Don't Know

        7. Are you over weight?

        Yes

        No

        8. Do you smoke or drink more than 21 units of alcohol per week?

          Yes

          No

          9. Have you been diagnosed with any of the following?

          • Allergy or reaction to previous impotence treatments
          • Heart disease including recent heart attack or angina (heart pain on exertion)
          • History of stroke or mini stroke (transient ischaemic attack)
          • History of vision problems due to poor circulation
          • Family history of the degenerative eye disease, including retinitis peigmentosa (rare)
          • Serious kidney/renal or liver disease
          • Deformity or angulation of the penis (Peyronie?s disease)
          • Sickle cell disease or leukaemia or multiple myeloma
          • A bleeding disorder (such as Haemophilia)
          • Active stomach ulcers (also known as peptic ulcer or gastric ulcer)
          Please consult your regular doctor before taking erectile dysfunction tablets. We are unable to prescribe tablets for you.

          Yes

          No

          10. Are you taking any of the following?

          • Existing ED treatment apart from Viagra/sildenafil, Cialis, Levitra or Spedra
          • Nitrates for angina or heart failure, includes glyceryl trinitrate, isosorbide mononitrate, isosorbide dinitrate, GTN spray or gel, or nicorandil
          • Ritonavir or Indinavir or medicine for HIV
          • Ketoconazole or itraconazole or other anti-fungal medication
          • The recreational drug amyl nitrate (Poppers)
          • Alpha-blockers (sometimes used to treat high blood pressure or prostate enlargement) includes alfuzosin, doxazosin, indoramin, prazosin, tamsulosin, terazosin
          Please consult your regular doctor before taking erectile dysfunction tablets. We are unable to prescribe tablets for you.

          Yes

          No

          11. Have you been advised to avoid vigorous exercise?

          • E.g. severe heart failure or unstable angina
          Please see your regular doctor before taking erectile dysfunction tablets. We are unable to prescribe tablets for you.

          Yes

          No

          12. Are you aware, if you have a continuous erection for 4 hours or more. you should seek immediate medical advice?

          • This is unlikely to happen and is rare. If it occurs you should seek medical advice straight away.
          If you have a continuous erection for 4 hours or more, you should seek medical advice straight away. You can change your answer and continue.

          Yes

          No

          13. Are you aware you should not take any combination of Viagra/sildenafil, Cialis, Levitra or Spedra, or use Vitaros cream or any other ED treatment, at the same time?

          • A break of up to 24 hours (36 hours for Levitra) should be left.
          You should not take any combination of Viagra/sildenafil, Cialis, Levitra or Spedra, or use Vitaros cream or any other ED treatment, at the same time - a break of up to 24 hours (36 hours for Levitra) should be left. You can change your answer and continue.

          Yes

          No

          14. Are you aware that Erectile Dysfunction medication is available on the NHS, only for certain medical conditions? If you don?t suffer from these medical conditions, the doctor may need to issue you with a private prescription. This will be free of cost.

            Yes

            No

            15. Do all of the following apply to you?

            • I will read the patient information leaflet supplied with my medication.
            • The medication is for my own use. (Partners, spouses etc must log out, complete their own consultation and register separately)
            The conditions must apply for you to be able to use this service.

            Yes

            No