Viagra Connect Pharmacist Consultation

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In order for our pharmacists to asses whether you can safely take Viagra Connect, please complete the following questions. All answers are strictly confidential.
It is recommended that all men see their GP within the first 6 months of starting to use Viagra Connect. This is to ensure 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.
Viagra Connect is only intended for men 18 years and older.

Name *

Phone number *

Date of Birth *

YYYY

Have you purchased Viagra Connect from a pharmacy in the last 6 months? *

Yes

Are you experiencing erectile dysfunction (ED) (i.e. difficulty in getting and/or maintaining an erection satisfactory for sexual performance) *Product options *

Yes

Has your doctor advised that you are not fit enough for any physical and/or sexual activity? *

Yes

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

Have you had a heart attack or stroke within the last 6 months? *

Yes

Do you have any other heart problems or are you under a doctors 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 (eg Left ventricular outflow obstruction, aortic narrowing) or severe cardiac failure

None of the above

Are you taking nitrates or any medication (nicorandil or other nitric oxide donors e.g. glyceryl trinitrate, isosorbide mononitrate or isosorbide dinitrate) for chest pain? *

Yes

Are you using drugs called ‘poppers’ for recreational purposes (e.g. amyl nitrite)? *

Yes

Are you taking riociguat or other guanylate cyclase stimulators for lung problems? *

Yes

Are you taking ritonavir (for HIV infection)? *

Yes

Are you taking any CYP3A4 inhibitors, e.g. saquinavir (to treat HIV infection), cimetidine (a heartburn treatment), itraconazole or ketoconazole (to treat fungal infections), erythromycin or rifampicin (antibiotics) or diltiazem (for high blood pressure)? *

Yes

Are you taking 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? *

Yes

Do you have Peyronie’s disease or any other deformation of the penis? *

Yes

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)? *

Yes

Do you have galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption? *

Yes

Do you have previously diagnosed hepatic (liver) disease (including cirrhosis of the liver) or severe renal (kidney) impairment? *

Yes

Do you have any bleeding issues (e.g. haemophilia) or have active stomach ulcers? *

Yes

Confirmation *

I confirm that the information I have given is correct to the best of my knowledge. I am aware that Molloys Pharmacy will retain this questionnaire for a period of two years in line with Data Protection Requirements.

Required

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