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ED Medical Intake Form

You have purchased a prescription product. To complete your order complete the form below and we will forward your information to one of our participating providers who can treat you from the comfort of your home.

Order #*

Please enter the order number found on the Order Confirmation email that you received. Your information will only be viewed by our Medical Team and is stored on HIPAA compliant servers.

First Name*
Last Name*
Phone Number *
Email *
Address*
City *
State Of Residence*
Zip Code*
Height*
Weight*
Are you allergic to any medication? *
What medications or vitamins are you taking? *
What is your date of birth? *
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? *



Premature ejaculation, coming 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?*


How did your ED begin? Select the one that best describes your ED.*

Do you get erections when masturbating?*



Do you get erections when asleep or first thing in the morning?*



Did your ED begin with a new sexual partner?*

Enter your blood pressure reading taken within the last 6 months. For Example Systolic 120 / Diastolic 80*
Blood Pressure Scale Chart
Have you had a physical exam by a doctor in the past 5 years? If you have not, we recommend you see a doctor before using our service. Select one of the following:*

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. Select one of the following:*


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)?*



Over the past 2 weeks, how often have you been bothered by little interest or pleasure in doing things?*



Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?*



Over the past 2 weeks, how often have you been bothered by feeling nervous, anxious, or on edge?*



Over the past 2 weeks, how often have you been bothered by worrying too much about different things?*



ED can be related to tobacco, alcohol, or drug use. Select all that apply to you.*




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.*








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.*




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.*












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.*





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.*



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.*







It can be life-threatening to take ED medicines if you take any of the following medicines. Instead, you should see a doctor in person and not use our service. Select all that apply to you.*






Are you allergic to any medicines?*

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.*















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.*
















Did you have any side effects from your previous ED medicines that would stop you from using them again?*


Other than prescription medicines, have you used other treatments for ED 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.*

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?*

You can always access your medical record from your account screen. Would you like us to also mail a copy to your doctor?*

Finally, is there anything else we should know?*

We must have a clear photo of your face and your photo ID so that we may properly identify and treat you. Your information is kept strictly private. We are a HIPAA compliant website. Take a pic right from your phone or upload a photo from your computer.
Faceshot
Photo ID
Only the medical team will see your photos

Note: Your medical information will not be saved until you click on the SUBMIT button.