Cialis Pharmacist Consultation

In order for our pharmacists to asses whether you can safely take Cialis , please complete the following 8 questions. All answers are strictly confidential.
It is recommended that all men starting this medication see their GP without delay and certainly within 6 months. This is to check that your symptoms of erectile dysfunction are not being caused by any underlying conditions.
The person intending to take this medication must be the person to complete this form.

Email *

Your Name

Do you, or have you ever had a problem with your heart or blood vessels (e.g. heart attack, stroke, low or high blood pressure or feeling dizzy)? *

Yes
No
Unsure

Do you feel very breathless or get chest pain if you walk fast for 20 minutes or climb 2 flights of stairs? *

Yes
No
Unsure

Have you ever been prescribed any nitrate medicine used to treat or prevent chest pain (angina), heart attack or heart failure? *

Yes
No
Unsure

Are you using recreational drugs called "poppers" (e.g. amyl nitrite)? *

Yes
No
Unsure

Do you have any health conditions?
For example:
• Problems with your liver or kidneys
• Blood diseases (e.g. leukaemia, sickle cell andemia, multiple myeloma *

Yes
No
Unsure

Have you ever had loss of vision because of damage to your optic nerve (known as NAION)? *

Yes
No
Unsure

Do you have Peyronie's disease or any other condition causing a change in the shape of your penis? *

Yes
No
Unsure

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Thanks for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Your Request Could Not Be Approved

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