Use the calendar to select your date of birth. 

Your height is important for the prescribers decision.

Please make sure to add your current weight. This may affect the prescriber's decision.

Use the following as a guide:

Low = Under 90/60
Normal = Between 90/60 and 140/90
High = Over 140/90

If you do, please write how many cigarettes you smoke per day. Or, if you vape, please tell us about this.

If so, please tell us how many units per day. You can use the following as a guide:

- Pint of beer = 3 units
- A can of beer = 2 units
- A large glass of red wine = 3 units

If so, please provide more information

If you cannot, please provide more information

You've had a heart procedure, a stroke, or a heart attack in the last five years. You have angina, aortic stenosis, heart failure, cardiomyopathy, high blood pressure that is uncontrolled (greater than 160/90), arrhythmia, or severe heart disease. You have suffered low blood pressure, fainting, or feeling dizzy when you stand up after lying down in the past. Diabetes (type I or type 2) or blood sugar levels that are abnormal. Medical diseases that impact the eyes, such as glaucoma or degenerative eye disease, as well as a family history of these conditions. Peyronie's disease is a deformity or angulation of the penis. Sickle cell disease, leukemia, or multiple myeloma are all examples of blood cancers. A disease that causes bleeding

Please list all your current prescription medication including any medication you buy over the counter.

If so, please provide more information

If so, please provide more details

If so, please provide more information