• Important
  • Erectile Dysfunction
  • More Details
  • Consent
Our doctors would now like to check your suitability for this product

How did you hear about us?

I confirm the all We are now going to ask you a few questions so that we can give you the best medical care. This takes an average of 5 minutes to complete.

We try our best to help our patients, but sometimes our online service is not able to meet all your needs.

Please be honest and if you are unsure about any of the answers, check these with your GP first
--I am 18 years old or above
--I am using this service on my own behalf and of my own free will and any treatment or advice is for my sole use only
--I will see my GP if I need help filling out this form, reading or understanding this consultation
--I understand my consultation will not be passed to the Your Chemists Online Doctor clinical team until I have successfully completed payment


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

What is your sex?

What is your date of birth?

Do you have a treatment preference? Our clinicians will review your answers and take this into account before deciding what\'s suitable for you.


ED details

How did your ED begin?

Do you get normal erections in the mornings or when you masturbate?

Has your sex drive gone down?

Do you have, or have you ever had, any heart conditions?

Have you ever had a stroke or mini-stroke (TIA)?

Do you have any of the following blood pressure problems?

What was your blood pressure?

Do you have a blood clotting condition that increases your risk of having blood clots, such as sickle cell anaemia, multiple myeloma or leukaemia?

Do you have a condition that affects your blood\'s ability to clot and makes you more prone to bleeding?

Have you ever had a liver condition?

Have you ever had a kidney condition?

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

Do you suffer from any inherited eye disorders such as retinitis pigmentosa?

To help us advise on the best treatment for you, please tick if you have any of the following:

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

During the last month have you been feeling down or had little interest or pleasure in doing things?

Do you take medicines for any of the following conditions?

Are you taking any of the following medication?

And finally, are you taking any prescription medications that you have not already told us about?

Do you have any allergies?

How many days a week do you drink alcohol?


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

Do you smoke?

Do you use cannabis?

Do you use any other recreational drugs such as cocaine or ecstasy?

Please enter your height(cm).

Please enter your weight(kg).

Have you taken any medications for erectile dysfunction before?


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

I confirm the all Please confirm the following to complete your consultation:

--I have responded honestly and provided complete and accurate information that reflects my up to date medical history and information, so that the clinician can safely assess and advise me.
--I fully understand all the questions and information provided. If I am unsure about any aspect of the service I will contact before proceeding.
--I understand the side effects, effectiveness and alternatives to the treatment I am requesting.
--I understand the importance of notifying my GP about medicines and advice I may receive from this service so they can continue to provide safe medical care.
--I understand this consultation will form part of my Online Doctor medical record and will be kept in line with the relevant retention period.
--I have read, understand and agree to the terms and conditions and privacy policy notice.


0% of questionnaire complete