Question 1

What was your gender assigned at birth?

This information helps our clinical team assess whether the treatment is suitable for you.

Female Male

Please select an answer before continuing.

Question 2

What is your date of birth?

You must be aged 18 or over to use this service.

Date of birth

Please enter a valid date of birth.

Question 3

Are you menopausal?

Yes No

Please answer all questions shown before continuing.

Question 4

What symptoms are you currently experiencing?

Please select the one option that best describes your main symptom.

Difficulty Achieving Orgasm Lack of Spontaneous Desire Difficulty Becoming Aroused Other

Please select one option and complete the additional details if required.

Question 5

How long have you experienced these symptoms?

Please select the one option that best applies.

1–3 months 6 months–1 year Lifetime

Please select an answer before continuing.

Question 6

Are there any new stressors in your life?

Yes No

Please select an answer before continuing.

Question 7

Are you pregnant or breastfeeding?

Yes No

Please select an answer before continuing.

Question 8

Do you have any of the following medical conditions?

Select all that apply.

Abnormal Heartbeat or Arrhythmias Chest Pain or Shortness of Breath Condition Where You Were Advised That Sex or Strenuous Activity May Be Dangerous Heart Attack, Chest Pain or Angina Heart Valve Problems Cardiomyopathy or Enlarged Heart Low Blood Pressure or History of Passing Out Stroke High Blood Pressure (Unmanaged) Change in Abnormal Heartbeat/Arrhythmia/Heart Palpitations None

Please select at least one answer before continuing.

Question 9

Do you have genital herpes?

Your answer will be reviewed by the prescribing team.

Yes No

Please answer all required questions before continuing.

Question 10

Do you have any allergies to the following medications?

Select all that apply.

Sildenafil Pentoxifylline Ergoloid Mesylates L-Arginine Aminophylline None

Please select at least one answer before continuing.

Question 11

Anything else the medical team should know?

Yes No

Please select an answer and provide details if required.

Question 12

Provide your GP details

This is optional and may be used for continuity of care where clinically appropriate.

GP practice, GP name or practice address (Optional)

Question 13

Before your prescription can be issued

Please confirm each statement and choose your preferred treatment option.

I understand this is a custom compounded medicine with a 30-day shelf life and it cannot be returned once dispensed.

Yes No

Scream Cream has a good success rate, but is not 100% effective for every patient. It may take a few attempts for the product to work and in some instances the dosing may have to be adjusted by the prescriber over time.

Yes No

I agree to inform She Can Health and my GP if my medical history changes, I become pregnant, start new medication, or experience side effects. I understand this medication is prescribed solely for my personal use and that transfer to a partner may occur if the cream is not fully absorbed.

Yes No

Select treatment option

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Is there anything else you would like to see She Can Health carry?

You must agree to all three statements and select a treatment option before continuing.

What was your gender assigned at birth?

What is your date of birth?

You must be 18 or older

Are you menopausal?

What symptoms are you currently experiencing?

How long have you experienced these symptoms?

Are there any new stressors in your life?

Are you pregnant or breastfeeding?

This treatment is not currently suitable

Do you have any of the following medical conditions?

Do you have genital herpes?

Are you on suppression medication?

Are your outbreaks well controlled?

Do you have any allergies to the following medications?

Anything else the medical team should know?

Provide your GP details

Before your prescription can be issued

Select treatment option

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