What is your first and last name?

First Name

Last Name

I agree to all the terms and conditions mentioned herein

What is your gender?

Male

Female

What is your date of birth?

Day

01

01
02
03
04
05
06
07
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09
10
11
12
13
14
15
16
17
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19
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25
26
27
28
29
30
31

Month

January

January
February
March
April
May
June
July
August
September
October
November
December

Year

01

2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
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1991
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1921
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1919
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1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900

Do you have any medical conditions?

No

Yes

Heart disease

Your health is our #1 priority. Please provide more details below:

Diabetes

What was your most recent A1C level?

Less than < 6%

7-8%

8-10%

Greater than > 10%

Not sure

Hyperlipidemia

Is this condition adequately being maintained by your medical provider?

Yes

No

Vascular disease

Is this condition adequately being maintained by your medical provider?

Yes

No

Emotional problems

Please provide more details below:

Kidney disease

Is this condition adequately being maintained by your medical provider?

Yes

No

Trauma or injury to: penis, pelvis, perineum, testes, or rectum

Prostate problems

Is this condition adequately being maintained by your medical provider?

Yes

No

Urinary problems

Is this condition adequately being maintained by your medical provider?

Yes

No

Sleep apnea

Chronic fatigue or weakness

Joint pains

Other

Please list your other medical conditions.

Has your therapist seen you within the past 3 years?

Yes, and it was normal

Yes, but there were issues

Please explain your exam and the issues in more detail.

No, I haven’t had a physical exam in the past 3 years

What effect have your sexual problems had on your relationships?

Little or no effect

Moderate effect

Large effect

With sexual stimulation can you...

Initiate an erection

How satisfied are you with the rigidity of your erection during sexual activity?

Strongly Dissatisfied

Dissatisfied

Neither satisfied nor dissatisfied

Satisfied

Strongly satisfied

Maintain an erection

How satisfied are you with the rigidity of your erection during sexual activity?

Strongly Dissatisfied

Dissatisfied

Neither satisfied nor dissatisfied

Satisfied

Strongly satisfied

Neither initiate nor maintain an erection

Have you taken any of the following as treatment for erectile dysfunction?

Sildenafil (Viagra)

Was this treatment effective?

Yes

No

Tadalafil (Cialis)

Was this treatment effective?

Yes

No

Vardenafil (Levitra)

Was this treatment effective?

Yes

No

Avanafil (Stendra)

Was this treatment effective?

Yes

No

Testosterone Replacement

Was this treatment effective?

Yes

No

Injections

Was this treatment effective?

Yes

No

None of the above

Have you taken any of the following drugs within the last three months?

Clarithromycin

Please provide more details below:

Diltiazem

Please provide more details below:

Erythromycin

Please provide more details below:

Itraconazole

Please provide more details below:

Ritonavir

Please provide more details below:

Verapamil

Please provide more details below:

Doxazosin mesylate (Cardura)

Please provide more details below:

Prazosin hydrochloride (Minipress)

Please provide more details below:

Terazosin hydrochloride (Hytrin)

Please provide more details below:

Hormones

Sedatives

Ulcer medications

Other medications

Please provide more details below:

None of the above

Have you ever been prescribed nitrates/nitroglycerin?

No

Yes

In the past several months, have you had any of the following:

Chest Pain

Passing Out

Dizziness/Seizure

None of the above

Have you had any surgeries?

No

Yes

Is there a family history of any of the following?

Cardiovascular disease

Please provide details of family history of cardiovascular disease (family members, relationship, age of onset)

Unexplained sudden death

None of the above

Do you drink alcohol every day?

No

Yes

In The Last Three Months, Have You Used Any Of The Following Drugs Recreationally?

Cocaine

Poppers or Rush

Methamphetamine

Molly (MDMA)

Opiates

Please provide additional details here

Heroin

Please provide additional details here

Other

Please provide additional details here

None

Do you exercise regularly?

No

Yes

Do you have any extra information to share with the doctor?

No

Yes

Have you had elevated Blood pressure in the past 6 months?

No

Yes

Enter your blood pressure reading taken within the last 6 months.

Low
100/60 or lower

Normal
101-139/61-89

High
140-159/90-99

Very High
160/100 or higher

Do you have any allergies?

No

Yes

Are you on any medications?

No

Yes

Which of the following applies to you?

I get less than 2 hours of exercise per week

I do not eat as healthy as I would like

I smoke or use tobacco (e.g., chewing tobacco, snuff)

I use other nicotine containing products

I drink more than 2 alcoholic drinks per day

I get less than 7 hours of sleep per night, on average

I'm 25+ pounds overweight

I am frequently under a lot of stress

None apply to me

Have you experienced any of the following conditions?

Enlarged prostate

Weight gain / management

Sleep / insomnia

Hair loss

Low testosterone

Blood sugar / diabetes

Acne / Rosceca / Hyperpigmentation

Joint Issues

Toe nail fungus

Pain management

None apply to me

What is your first and last name?

What is your gender?

What is your date of birth?

Do you have any medical conditions?

Has your therapist seen you within the past 3 years?

What effect have your sexual problems had on your relationships?

With sexual stimulation can you...

Have you taken any of the following as treatment for erectile dysfunction?

Have you taken any of the following drugs within the last three months?

Have you ever been prescribed nitrates/nitroglycerin?

In the past several months, have you had any of the following:

Have you had any surgeries?

Is there a family history of any of the following?

Do you drink alcohol every day?

In The Last Three Months, Have You Used Any Of The Following Drugs Recreationally?

Do you exercise regularly?

Do you have any extra information to share with the doctor?

Have you had elevated Blood pressure in the past 6 months?

Enter your blood pressure reading taken within the last 6 months.

Do you have any allergies?

Are you on any medications?

Which of the following applies to you?

Have you experienced any of the following conditions?

Please remember!