Are you a male?

Have you used any erectile dysfunction medication before?

Do you have any problems getting an erection, or keeping one as long as you want to?

Do you have high blood pressure (above 150/90)?

If you do not know your blood pressure you can have this measured at your local pharmacy or GP practice.

Do you have a history of low blood pressure (below 90/50), signs of this include fainting or, after lying down do you get dizzy when you stand up?

If you do not know your blood pressure you can have this measured at your local pharmacy or GP practice.

Do you often get breathless or have chest pain when you do light exercise, like walking up stairs?

In the last 6 months, have you been told by a doctor to avoid physical or sexual activity?

Do you suffer or have ever suffered from any of the following problems?

Heart problems (e.g. angina, chest pain, heart failure, or anything heart related)
Stroke
Kidney problems
Liver problems
Loss of vision because of non-arteritic anterior ischemic optic neuropathy (NAION)
Active stomach ulcers (Also known as a peptic or gastric ulcer)
An erection that lasted more than 4 hours
History of stroke or mini stroke (Transient ischaemic attack)
Blood problems such as sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood cells), multiple myeloma (cancer of bone marrow)
Bleeding problems such as haemophilia
Galactose intolerance, Lapp Lactase deficiency or glucose-galactose malabsorption
Multiple myeloma (cancer of the bone marrow)
Retinitis pigmentosa (rare inherited eye disease)

Would you have any difficulty walking at a fast pace for 5 minutes?

Are you taking any of the following? If you are not sure then check with your GP or contact us.

Any treatment for erectile dysfunction apart from Spedra (avanafil), Viagra (sildenafil) , Levitra (vardenafil) or Cialis (tadalafil)
Any form of organic nitrate. This is a group of medicines (“nitrates”) used in the treatment of angina pectoris (“chest pain”)
* An alpha blocker (used to treat high blood pressure or urinary symptoms associated with benign prostatic hyperplasia))

* Anti-fungal medication such as Ketoconazole or itraconazole

* Erythromycin/clarithromycin/cimetidine

* Medicines to treat high blood pressure

* Medicines such as ketoconazole tablets (to treat fungal infections) and protease inhibitors such as ritonavir or indinavir for treatment of AIDS or HIV infection

* Nitric oxide donors such as amyl nitrite (“poppers”)

* Nicorandil

* Quinidine/procainamide/amiodarone

* Phenobarbital, phenytoin and carbamazepine (anticonvulsant medicines)

* Theophylline

Do you have an allergy (hypersensitivity) to Spedra (avanafil), Viagra (sildenafil) , Levitra (vardenafil) or Cialis (tadalafil)?

Do you agree to the following?

* You will seek medical attention if you experience any unusual side effects

* You will read the patient information leaflet supplied with your medication

*The treatment is solely for your own use

What is the name of your GP surgery? Do you consent to us contacting them about your treatment?