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Erectile Dysfunction
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Please list all medications prescribed to you even if you don't take them every day. Include vitamins, and dietary supplements. Enter medicines including name, dose, frequency, and reason for taking.
Please list your allergies, including allergies to medications.
What is your height?
What is your weight?
Phone type
Cell
Home
Work
Night
Primary
What's the best method to contact you?
Text
Email
Phone
Call
What is your date of birth?
MM slash DD slash YYYY
Gender
Female
Male
Do you ever have a problem getting or maintaining an erection that is satisfying enough for sex? If you do not have a problem with an erection, you should not use our service. Which of the following apply to you?
Yes, everytime I want an erection
Yes, sometimes when I want an erection
Yes, rarely when I want an erection
No, never have problems with an erection
Premature ejaculation, ejaculating either before or shortly after sex (penetration) starts, can occur in some men. If this is the only problem you have with sex, you should see a doctor in person and not use our service. Which of the following apply to you?
Only have problems with premature ejaculation. Never have problems with an erection.
Have problems with both premature ejaculation and erection.
None apply. Do not have premature ejaculation.
How did your ED begin? Select the one that best describes your ED.
Began suddenly one night when I could not perform and it has been the same ever since.
Began gradually and then got worse over time
Do you get erections when masturbating?
Yes
Sometimes
Rarely
No
Do you get erections when asleep or first thing in the morning?
Yes
Sometimes
Rarely
No
Did your ED begin with a new sexual partner?
Yes
No
Enter your blood pressure reading taken within the last 6 months. For Example Systolic 120 / Diastolic 80
Please reenter your blood pressure
Have you had a physical exam by a doctor in the past 3 years? If you have not, we recommend you see a doctor before using our service.
Yes
No
Did your physical exam include an exam of the genitals (including the testicles, penis)? If you have not, we recommend you see a doctor before using our service.
Yes, it was normal
No
The medicines we prescribe are only appropriate for certain patients. Which of the following best describes your sex drive or desire to have sex (libido)?
I still think about sex and want to have sex. My sex drive or desire to have sex is normal.
I do not think about sex or do not want to have sex because I have problems with having an erection.
I do not think about sex or do not want to have sex. My sex drive or desire to have sex is abnormal.
Other
Untitled
Over the past 2 weeks, how often have you been bothered by little interest or pleasure in doing things?
Not at all
Several days
More than half of the days
Nearly every day
Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?
Not at all
Several days
More than half of the days
Nearly every day
Over the past 2 weeks, how often have you been bothered by feeling nervous, anxious, or on edge?
Not at all
Several days
More than half of the days
Nearly every day
Over the past 2 weeks, how often have you been bothered by worrying too much about different things?
Not at all
Several days
More than half of the days
Nearly every day
ED can be related to tobacco, alcohol, or drug use. Select all that apply to you.
Smoke cigarettes or use other tobacco products
Use a recreational drug called amyl nitrate or butyl nitrite (Poppers, Rush)
Use other recreational drugs
None apply
what are the names of those drugs you use recreationally?
Do you drink alcohol?
Yes
No
How often do you drink alcohol?
1-2 drinks per day
3-4 days per week
1-2 drinks per month
A few times per year
Other frequency
Other frequency
Some cases of ED are too complex for us to manage effectively online. Instead, you should see a doctor in person and not use our service. Do you have any of these conditions? Select all that apply to you.
Any condition where sex is not advised
Kidney disease
Liver disease
Neurological problems like multiple sclerosis or motor neuron disease
HIV
Spinal injury
Paralysis
Previous surgery on your prostate or pelvis
Radiation therapy to your pelvis
Any organ transplant
None apply
what organ was transplanted?
Are you taking any immunosuppressive therapy?
Yes
No
Some genital issues can cause difficulty with sex and you should see a doctor in person and not use our service. Do you have any of these conditions? Select all that apply to you.
Physical abnormalities of the penis, curving or bending of the penis making it hard for sex
Peyronie's disease
Scarring of the penis (it feels like lumps or hard tissue under the skin)
Pain with erections
Tight foreskin
None apply
It can be life-threatening to take ED medicines if you now HAVE or HAVE EVER had any of the following heart, blood pressure, or cardiovascular problems. Instead, you should see a doctor in person and not use our service. Select all that apply to you.
High blood pressure
High cholesterol
Diabetes
Low blood pressure
Angina
Heart attack
Heart failure
Stroke
History or family history of QT prolongation
Heart arrhythmia
Heart valve problems
Hypertrophic obstructive cardiomyopathy (HCM)
Peripheral vascular disease or claudication
HIV
None apply
When was your heart attack?
What was your last A1C?
What is the name of the heart arrhythmia?
Please list all HIV medications prescribed to you.
Certain symptoms can be a sign of a more serious medical problem and you should see a doctor in person and not use our service. When taken with ED medicines, these can cause a life-threatening problem. Select all that apply to you.
Chest pain when climbing 2 flights of stairs or walking 4 blocks
Shortness of breath when climbing 2 flights of stairs or walking 4 blocks
Chest pain with sexual activity
Shortness of breath with sexual activity
Unexplained fainting or dizziness
Cramping of the legs with exercise
Abnormal heartbeats or rhythms
None apply
Are you being followed by a cardiologist? Have you discussed ED medications with your providers?
ED can be the first sign of heart disease. Depending on your risk factors, you may need to see a doctor in person and not use our service. Which of the following additional risk factors do you have for heart disease? Select all that apply to you.
High cholesterol
My father had a heart attack or heart disease at 55 years or younger
My mother had a heart attack or heart disease at 65 years or younger
None apply
It can be life-threatening to take ED medicines if you now have or have ever had any of the following medical conditions. Instead you should see a doctor in person and not use our service. Select all that apply to you.
Priapism (erection lasting longer than 4 hours)
Retinitis pigmentosa
Anterior ischemic optic neuropathy (AION)
Sickle cell disease
Blood clotting disorder, abnormal bleeding or bruising, or coagulopathy
Myeloma or leukemia
Stomach or intestinal ulcer
None apply
It can be life-threatening to take ED medicines while taking other prescribed medications. Instead, you should see a doctor in person and not use our service. Select all that apply to you.
Nitroglycerin spray, ointment, patches or tablets (Nitro-Dur, Nitrolingual, Nitrostat, Nitromist, Nitrolingual, Nitro-Bid, Transderm-Nitro, Nitro-Time, Deponit, Minitran, Nitrek, Nitrodisc, Nitrogard, Nitroglyn, Nitrol ointment, Nitrong, Nitro-Par)
Isosorbide mononitrate or isosorbide dinitrate (Isordil, Dilatrate, Sorbitrate, Imdur, Ismo, Monoket)
Other medicines containing nitrates
Alpha blockers to treat high blood pressure or prostate problems, including doxazosin (Cardura), prazosin (Minipress), alfuzosin (Uroxatral), silodosin (Rapaflo), tamsulosin (Flomax), terazosin (Hytrin)
Sildenafil (Revatio) used to treat pulmonary hypertension
Riociguat (Adempas) used to treat pulmonary hypertension
None apply
Are you allergic to any medicines? Be sure to include any allergies to galactose, phenylalanine, or to any ED medicines, including but not limited to: avanafil (Stendra), sildenafil (Revatio / Viagra), tadalafil (Cialis), and vardenafil (Levitra, Staxyn).
Yes
No
Which of the following prescription ED medicines have you taken in the past, regardless of whether they worked well? SELECT ALL THAT APPLY TO YOU
Never took any prescription ED medicines
Avanafil (Stendra) 50 mg
Avanafil (Stendra) 100 mg
Avanafil (Stendra) 200 mg
Sildenafil (Viagra, Revatio) 25 mg
Sildenafil (Viagra, Revatio) 50 mg
Sildenafil (Viagra, Revatio) 100 mg
Tadalafil (Cialis, Adcirca) 2.5 mg
Tadalafil (Cialis, Adcirca) 5 mg
Tadalafil (Cialis, Adcirca) 10 mg
Tadalafil (Cialis, Adcirca) 20 mg
Vardenafil (Levitra) 2.5 mg
Vardenafil (Levitra) 5 mg
Vardenafil (Levitra) 10 mg
Vardenafil (Levitra) 20 mg
Other
None apply
Of the prescription ED medicines you just told us about, which ones worked to your satisfaction, regardless of whether you are currently taking them? SELECT ALL THAT APPLY TO YOU.
Never took any prescription ED medicines
Avanafil (Stendra) 50 mg
Avanafil (Stendra) 100 mg
Avanafil (Stendra) 200 mg
Sildenafil (Viagra, Revatio) 25 mg
Sildenafil (Viagra, Revatio) 50 mg
Sildenafil (Viagra, Revatio) 100 mg
Tadalafil (Cialis, Adcirca) 2.5 mg
Tadalafil (Cialis, Adcirca) 5 mg
Tadalafil (Cialis, Adcirca) 10 mg
Tadalafil (Cialis, Adcirca) 20 mg
Vardenafil (Levitra) 2.5 mg
Vardenafil (Levitra) 5 mg
Vardenafil (Levitra) 10 mg
Vardenafil (Levitra) 20 mg
Other
None apply
Did you have any side effects from your previous ED medicines that would stop you from using them again?
No, never taken ED medicines before
No, never had side effects that bothered me
Yes
What side effects did you experience? With which ED medication?
Other than prescription medicines, have you used other treatments for ED in the past?
No, never used other treatments
Yes
What other treatments for ED have you used in the past?
Are you currently taking any other prescription medicines for other medical issues? Also include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids.
Yes
No
ED can be the first sign of hardening of the arteries and heart disease. We recommend lab tests to determine your risk. Labs are especially important if this is your first ED diagnosis. Do you want us to order blood tests to check for underlying causes?
No, but I understand they are recommended tests
Yes
You can always access your medical record from your account screen. Would you like us to also mail a copy to your doctor?
Yes, please mail my medical record to my doctor
No
Finally, is there anything else we should know?
Yes
No
Please briefly explain.
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