Erectile Dysfunction Name(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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 typeCellHomeWorkNightPrimaryWhat's the best method to contact you?TextEmailPhoneCallWhat 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 pressureHave 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. Erectile Dysfunction Name(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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 typeCellHomeWorkNightPrimaryWhat's the best method to contact you?TextEmailPhoneCallWhat 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 pressureHave 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.
