Erectile Dysfunction Form

• Stroke.
• Blood problems such as haemophilia, sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood cells).
• Liver problems.
• Kidney problems.
• Sight loss due to poor circulation or non-arteritic anterior ischemic optic neuropathy (NAION).
• Heart problems, including angina, chest pain, heart failure, irregular heart beats, heart attack (myocardial infarction), left-ventricular outflow obstruction, cardiomyopathy, or valvular heart disease (e.g., aortic stenosis).
• Stomach ulcers (e.g. peptic/gastric ulcer).
• An erection that lasted more than 4 hours.
• Any physical condition affecting the shape of the penis (e.g. angulation, Peyronie’s disease, and cavernosal fibrosis).
• Inherited eye disease - retinitis pigmentosa.
• Multiple myeloma (cancer of the bone marrow).
• Lactose intolerance
• Any serious medical condition which may require immediate hospitalization

• You understand in the rare event I obtain a prolonged erection for more than 4 hours I will seek immediate medical attention
• I will read the Patient information leaflet before starting my medication
• I will contact my GP or pharmacy if I suffer from any adverse effects to the medication
• I have answered all the questions and statements truthfully and understand if I have falsified information I may be putting my own health in jeopardy
• I understand that the prescriber will review my information and based on my answers will decide whether or not the medication is safe for me
• I understand that if my GP is unaware of my erectile dysfunction, I will inform them at the earliest convenience in order to rule out any serious underlying health conditions such as Cardiovascular issues, High cholesterol, Hypertension or diabetes.
• I understand that the pharmacist may require access to my Summary Care Records (SCR) to double-check any contraindicating medications I may be on. In this case, I consent to the pharmacist and solely the pharmacist to view my SCR.

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