Vardenafil

• If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

• Any heart problems including angina, chest pain, heart failure, irregular heart beats, heart attack (myocardial infarction), left-ventricular outflow obstruction, cardiomyopathy or valvular heart disease (e.g.aortic stenosis).
• Stroke
• Sight loss due to poor circulation
• Sight loss because of non-arteritic anterior ischemic optic neuropathy (NAION)
• Blood problems such as haemophilia, sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood cells)
• Stomach ulcers (e.g. peptic/gastric ulcer)
• Liver problems
• Kidney problems
• An erection that lasted more than 4 hoursAny physical condition affecting the shape of the penis (e.g. angulation, Peyronie’s disease and cavernosal fibrosis)
• 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

Please provide the name(s) and the doses(s) of all medication used

• Any medication known as nitrates for chest pain/angina, amyl nitrite (poppers) or GTN spray
• Alpha-blockers e.g. Tamsulosin, Doxazosin, Terazosin etc.
• Antibiotics e.g. Erythromycin, Rifampicin
• Anti-fungals e.g. Ketoconazole
• Cimetidine for Heartburn
• Anti-depressants e.g. Setraline, Citalopram etc.
• Any HIV or Cancer medication
• Medication to treat stroke, heart disease or blood pressure
• Riociguat to treat pulmonary hypertension

• You will read the patient information leaflet supplied with your medication
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
• The treatment is solely for your own use
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
• You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber.