Prostate Enlargement

Have you been experiencing any of the following symptoms for the last 3 months or more?

• Difficulty starting to urinate
• Straining to urinate and/or unintentionally leaking urine
• Weak flow or where urination is starting and stopping
• Frequent or urgent need to urinate
• Getting up regularly in the night to urinate
• Not completely emptying your bladder

Have you ever had a history of?:

• Postural hypotension ( Low blood pressure on sitting/standing up)
• Heart problems including heart failure, unstable angina or left-ventricular outflow obstruction such as aortic stenosis
• Kidney or liver disease
• Uncontrolled diabetes
• Undiagnosed cloudy/blurred vision
• Urinary incontinence

Are you currently taking any of the following medications?:

• Doxazosin
• Indoramin
• Prazosin
• Terazosin

• I have answered all the above questions in full accurately and truthfully and I will contact E Shop Pharmacy if there is any change to the above questions. I understand any incorrect information may be detrimental to my health
• I am requesting treatment for myself and any prescribed treatment will be for my sole use
• The information provided will be collected and processed in accordance with GDPR regulations. I agree for my information to be processed by the E Shop Pharmacy in order to provide any treatment and that the prescribers will ultimately have the final decision whether to prescribe any medication
• If I suffer any side effects from my treatment I will contact E Shop Pharmacy and or my GP immediately
• I will read the patient information leaflet before taking the medication and I will contact a health care professional if I have any questions relating to my treatment or the information contained within it
• I should inform my GP that I am taking this medication
• I am aware medication to treat prostate enlargement may cause dizziness or weakness and this may affect performance of skilled tasks such as driving. I agree that in the event of this, I should sit or lie down and not operate any machinery or drive until the symptoms have gone
• I understand I should have my blood pressure checked regularly as well as testing for diabetes, high cholesterol or hormone imbalances
• I agree to the terms and conditions and privacy policy