Part 2 of 4
Long-term medical condition & History
Your health
Do you have high blood pressure (above 160/90), or are you currently on treatment for high blood pressure?
Yes
No
Do you have low blood pressure (below 90/50)?
Yes
No
Do you have any long-term medical conditions including
- An erection that lasted more than 4 hours
- Inherited eye disease - retinitis pigmentosa
- Multiple myeloma (cancer of the bone marrow)
- Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption
- Any serious medical condition which may require immediate hospitalisation
- Sight loss due to poor circulation
- Do you have Peyronie’s disease or any other deformation of the penis?
- Have ever had loss of vision because of damage to the optic nerve (such as non-arteritic anterior ischaemic optic neuropathy [NAION]) or have an inherited eye disease (such as retinitis pigmentosa)?
- Do you have previously diagnosed hepatic (liver) disease (including cirrhosis of the liver) or severe renal (kidney) impairment?
- Do you have any bleeding issues (e.g. haemophilia) or have active stomach ulcers?
Yes
No
Do you have any other heart problems or are you under a doctor’s care for any of the following
- Low blood pressure or uncontrolled high blood pressure Unstable angina (chest pain), irregular heart beat or palpitations (arrhythmia)
- A problem with one of the valves in your heart (valvular heart disease)
- A problem where the heart muscle becomes inflamed and does not work as well as it should (cardiomyopathy)
- Heart problems causing blood flow issues (e.g. left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure
Yes
No
Have you had any of the following in the last 6 months?
Heart attack
Yes
No
Stroke
Yes
No
pain during exertion
Yes
No
Has your doctor advised that you are not fit enough for any physical and/or sexual activity?
Yes
No
Do you feel very breathless or experience chest pain with light or moderate physical activity, such as walking briskly for 20 minutes or climbing two flights of stairs?
Yes
No
Do you have previously diagnosed hepatic (liver) disease (including cirrhosis of the liver) or severe renal (kidney) impairment?
Yes
No
Do you have any bleeding issues (e.g. haemophilia) or have active stomach ulcers?
Yes
No
Are taking any of the following medications?
- Nitrates (nicorandil or other nitric oxide donors e.g. glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate) for chest pain?
- Using drugs called ‘poppers’ for recreational purposes (e.g. amyl nitrite)?
- Riociguat or other guanylate cyclase stimulators for lung problems?
- Ritonavir (for HIV infection)?
- Any CYP3A4 inhibitors, e.g. saquinavir (to treat HIV infection), cimetidine (a heartburn treatment), itraconazole or ketoconazole (to treat fungal infections), erythromycin (antibiotics) or diltiazem (for high blood pressure)?
- Any alpha-blockers, such as alfuzosin, doxazosin or tamsulosin, which are medicines to treat urinary problems due to enlarged prostate (benign prostatic hyperplasia) or occasionally to treat high blood pressure?
- Sacubitril/valsartan (Enstresto) to treat heart failure?
Yes
No
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