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Have you ever had an allergic reaction to Sildenafil or Tadalafil?

Yes No

Are you taking any long or short acting nitrates?

Yes No

Do you have a history of heart disease or coronary artery disease or liver problems?

Yes No

Do you have a history of diabetes or hyperlipidemia?

Yes No

Do you have a history of hypertension or hypotension?

Yes No

Have you ever had any retinal disorders or eye issues?

Yes No

Have you ever had a stroke?

Yes No