Front Up Questionnaire

To get going again, you need to know where to go first. It’s either going to be the pharmacist or your GP. Answer the six questions below to find out which one is right for you.

Your Name Your Name * First Last
1. ARE YOU BETWEEN 35 - 70 YEARS OLD? *

1. ARE YOU BETWEEN 35 - 70 YEARS OLD? Yes No
2. DO YOU SMOKE? *

2. DO YOU SMOKE? Yes No
3. ARE YOU TAKING ANY OF THE FOLLOWING?
- Ritonavir or Saquinavir
- Any other erectile dysfunction medication
- Any medication for diabetes, angina, high blood pressure or enlarged prostate, e.g. alpha blockers
*
3. ARE YOU TAKING ANY OF THE FOLLOWING?
- Ritonavir or Saquinavir
- Any other erectile dysfunction medication
- Any medication for diabetes, angina, high blood pressure or enlarged prostate, e.g. alpha blockers
Yes No
4. HAVE YOU HAD ANY OF THE FOLLOWING CONDITIONS?
- Previous cardiovascular problems, i.e Heart attack, angina, stroke
- Previous coronary intervention, i.e. Angioplasty, bypass surgery, valve replacement
- Any blood disorders, i.e. Sickle cell disease, leukaemia, multiple myeloma
- Any problems with your liver or kidneys?
- Deformity of your penis
- Diabetes
- Personal or family history of serious eye disorder excluding glaucoma or cataracts, i.e. Retinitis pigmentosa
- Sudden loss of vision in one or both eyes
- Low blood pressure (<90/50 mmHg) or high blood pressure (>170/110 mmHg)
*
4. HAVE YOU HAD ANY OF THE FOLLOWING CONDITIONS?
- Previous cardiovascular problems, i.e Heart attack, angina, stroke
- Previous coronary intervention, i.e. Angioplasty, bypass surgery, valve replacement
- Any blood disorders, i.e. Sickle cell disease, leukaemia, multiple myeloma
- Any problems with your liver or kidneys?
- Deformity of your penis
- Diabetes
- Personal or family history of serious eye disorder excluding glaucoma or cataracts, i.e. Retinitis pigmentosa
- Sudden loss of vision in one or both eyes
- Low blood pressure (<90/50 mmHg) or high blood pressure (>170/110 mmHg)
Yes No
5. HAVE YOU HAD A RECENT HEART OR DIABETES CHECK BY YOUR DOCTOR? *

5. HAVE YOU HAD A RECENT HEART OR DIABETES CHECK BY YOUR DOCTOR? Yes No
6. CAN YOU WALK BRISKLY FOR 5 MINUTES OR WALK UPHILL WITHOUT BECOMING BREATHLESS OR WITHOUT CHEST PAIN? *

6. CAN YOU WALK BRISKLY FOR 5 MINUTES OR WALK UPHILL WITHOUT BECOMING BREATHLESS OR WITHOUT CHEST PAIN? Yes No
Email *
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