Name *

First

Last

Email *

Phone *

How often do you experience difficulty getting or maintaining an erection for sexual activity? *

Always
More than half the time
Sometimes
Rarely
Never

Pick the scenario that best describes your ED. *

Difficulty achieving erections
Difficulty maintaining erections
Both

How did your ED start? *

Suddenly
Gradually worsened over time

Rate the typical hardness of your erection during masturbation.

Penis does not enlarge
Penis is larger, but not hard
Penis is hard, but not hard enough for penetration
Penis is hard enough for penetration, but not completely hard
Penis is completely hard and fully rigid

Do you have low sex drive? *

Have you ever been treated with medication for ED? *

Do you have a lack of energy? *

Which of the following treatments have you used to treat your ED in the past? *

Sildenafil (Viagra or generic)
Tadalafil (Cialis or generic)
Vardenafil (Levitra or generic)
Avanafil (Stendra)
Other

Please tell us more about your sildenafil usage. Which dosages did you try? Were they effective? *

Please tell us more about your tadalafil usage. Which dosages did you try? Were they effective? *

Please tell us more about your Vardenafil usage. Which dosages did you try? Were they effective? *

Please tell us more about your avanafil usage. Which dosages did you try? Were they effective? (copy) *

Please tell us more about your usage of other ED treatments. Which dosages did you try? Were they effective? *

When was your most recent in-person checkup with a healthcare provider? *

Within the last year
1-2 years ago
2-3 years ago
More than 3 years ago

Do you have a decrease in strength and/or endurance? *

What was your last blood pressure reading?

What was your top number? *

Less than 90 (Low)
90-139 (Normal)
140-169 (Elevated)
170 or higher (High)
I don't remember

What was your bottom number? *

Less than 50 Low
50-80 Normal
81-99 Elevated
100 or higher High
I don't remember

Do you take any medications, vitamins, or supplements regularly? *

Please list any current medicines, vitamins, or dietary supplements you take regularly, including the dosage. Include any medicines (e.g. Lipitor, Zyrtec, Ibuprofen) or any supplement taken in the past 2 weeks, even if you are not taking them daily. *

Do you take any of the following medications? Select all that apply. *

Nitroglycerin spray, ointment, patches or tablets (Nitro-Dur, Nitrolingual, Nitrostat, Nitromist, Nitro-Bid, Transderm-Nitro, Nitro-Time, Deponit, Minitran, Nitrek, Nitrodisc, Nitrogard, Nitroglycn, Nitrol ointment, Nitrong, Nitro-Par)
Isosorbide mononitrate, or isosorbide dinitrate (Isordil, Dilatrate, Sorbitrate, Imdur, Ismo, Monoket)
Other medicines containing nitrates
Nitric Oxide supplements/boosters
Non-uroselective alpha blockers, doxazosin (Cardura), prazosin (Minipress),terazosin (Hytrin)
Uroselective alpha blockers ((i.e. Flomax (tamsulosin), Uroxatral (alfuzosin), and Rapaflo (silodosin))
Riociguat (Adempas)
None Apply

Do you have any allergies? Include any allergies to food, dyes, prescriptions, or over-the-counter medicines (e.g. antibiotics, allergy medications), herbs, vitamins, supplements, or anything else. *

Please list what you are allergic to and the reaction that each one causes. *

Have you had any surgeries or hospitalizations? *

Please tell us the dates and reasons for any surgeries or hospitalizations. *

Do any of the following cardiovascular risk factors apply to you? *

Diabetes
High cholesterol
High blood pressure
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 to me

Please tell us your last hemoglobin A1c and how long ago it was taken. *

Do you experience any of the following cardiovascular symptoms? *

Chest pain or shortness of breath when climbing 2 flights of stairs or walking 4 blocks
Chest pain or shortness of breath with sexual activity
Unexplained fainting or dizziness
Prolonged cramping of the legs with exercise
Abnormal heart beats or rhythms
None of these apply to me

Do you have or have you previously been diagnosed with any of the following? Check all that apply.

Prostate conditions
Kidney diseases or conditions
Liver, stomach, or other gastrointestinal conditions
Nerve, spinal cord, or brain disorders
Eye conditions or diseases
Blood conditions or diseases
Heart conditions or diseases
Vascular conditions or diseases
Penis conditions other than ED
Other chronic medical conditions
None of these apply to me

Please tell us more about your prostate condition? *

Please tell us more about your Kidney condition? *

Please tell us more about your Liver, stomach, condition? *

Please tell us more about your nerve, spinal cord or brain disorder condition? *

Please tell us more about your Eye condition or disease? *

Please tell us more about your Blood condition or disease? *

Please tell us more about your Heart condition or disease? *

Please tell us more about your Vascular condition or disease? *

Please tell us more about your Penis condition or disease? *

Please list any chronic medical conditions. *

Do you currently or have you within the past 6 months, smoked or used any of the following recreational drugs? *

Poppers or Rush (Amyl Nitrate or Butyl Nitrate)
Cocaine
Cigarettes
Other
No I don't use any of these

Here's your first message to your clinician. Please introduce yourself and ask the clinician any questions you have about the treatment. Feel free to include anything else you want them to know about your condition. *

You are now ready to submit to your Doctor.

Please enter you Date of Birth... Month- Date-Year. *