Heads Up Questions
This is a free doctor's visit to gather the necessary health information in order for the doctor to write you a prescription for ED medication. If approved, the doctor will send the prescription to our pharmacy and you will contacted within 24-48 hours by our pharmacist.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Birthday
*
-
Month
-
Day
Year
Date
Sex assigned at birth
*
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How did your ED begin? Select the one that best describes your ED.
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Please Select
Gradually but has worsened overtime
Suddenly, with a new partner
Suddenly, with same partner
I do not recall
What effect, if any, has your sex problems had on your partner relationships?
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Please Select
No Effect
Little effect
Moderate effect
Large effect
How satisfied have you been with your sex life in the past 6 months?
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Please Select
Not at all
A little bit
Somewhat
Quiet a bit
Very
Do you have any of the following medical conditions? (Select all that apply)
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Heart disease
Diabetes
Hyperlipidemia
Vascular disease
Emotional problems
Kidney disease
Trauma or injury to: penis, pelvis, perineum, testes, or rectum
Prostate problems
Urinary problems
Sleep apnea
Chronic fatigue or weakness
Joint pains
None of the above
Other
Other: Please list your other medical conditions: (NA if not applicable)
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Have you seen your primary care doctor within the past 3 years?
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Yes
No
Are all of your medical issues being appropriately treated by your primary care provider?
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Yes
No:
If No: Please explain your medical issues not currently being treated by your primary care provider. (NA if not applicable)
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With sexual stimulation can you…?
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Please Select
Initiate an erection
Maintain an erection
Neither initiate nor maintain an erection
How satisfied are you with the rigidity of your erection during sexual activity?
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Please Select
Not at all
A little bit
Somewhat
Quite a bit
Very
How satisfied have you been with your ability to keep your erections as long as you wanted over the past six months, in general?
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Please Select
Not at all
A little bit
Somewhat
Quite a bit
Very
Have you taken any of the following as treatment for erectile dysfunction? (Select all that apply)
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Sildenafil (Viagra)
Tadalafil (Adcirca, Cialis)
Vardenafil (Levitra, Staxyn),Avanafil (Stendra)
Testosterone Replacement
Injections
Surgery or use of Pumps
Shock wave therapy
Intraurethural therapy (MUSE)
No I have never used any medication, supplement or behavioral modification to treat ED
Other
Other Treatment: Please list and describe. (NA if not applicable)
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If you have had treatment listed above for ED, please explain for each if the treatment was effective and provide dosage if applicable. Write NA if it does not apply to you. (NA if not applicable)
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Are you on any medications?Include any medicines (e.g., Lipitor, Zyrtec, ibuprofen), herbs, vitamins, or dietary supplements that you have taken in the past 2 weeks, even if you are not taking them today.
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Do you have any allergies? Include any allergies to food, dyes, prescription or over-the-counter medicines (e.g., antibiotics, allergy medications), herbs, vitamins, supplements, or anything else.
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In the last three months, have you taken any of the following drugs?(Select all that apply)
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Clarithromycin
Diltiazem
Erythromycin
Itraconazole
Ketoconazole
Ritonavir
Verapamil
Doxazosin mesylate (Cardura)
Prazosin hydrochloride (Minipress)
Terazosin hydrochloride (Hytrin)
Hormones
Sedatives
Ulcer medications
None of the above
If said yes to any of the drugs in question 13, please provide more details for each. (NA if not applicable)
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Have you ever been prescribed nitrates/nitroglycerin?If Yes: Please provide as much detail as possible. When was the last time you were prescribed nitrates/nitroglycerin?
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In the past several months, have you had any of the following: (Select all that apply)
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Chest Pain
Passing Out
Dizziness/Seizure
Shortness of breath or trouble breathing
Abnormal heartbeat
None of the above
Have you had any surgeries? If Yes: Please list all surgeries you've had
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Is there a family history of any of the following?
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Cardiovascular disease
Unexplained sudden death
None of the above
If applicable, please provide details of family history of cardiovascular disease or unexplained sudden death (family members, relationship, age of onset). (NA if not applicable)
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Over the past two weeks how often have felt little or no pleasure in activities you usually enjoy?
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Please Select
Not at all
Several days
More than half the days
Nearly every day
Over the past two weeks how often have felt down, depressed, or hopeless?
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Please Select
Not at all
Several days
More than half the days
Nearly every day
Over the past two weeks how often have felt nervous, anxious, on edge, or worrying too much?
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Please Select
Not at all
Several days
More than half the days
Nearly every day
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Which of the following apply to you? (Select all that apply)
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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 (e.g., vaping)
I drink more than 2 alcoholic drinks per day
I get less than 7 hours of sleep per night, on average
I'm 20+ pounds overweight
I am frequently under a lot of stress
None apply to me
In The Last Three Months, Have You Used Any Of The Following Drugs Recreationally?
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Cocaine
Poppers or Rush
Opiates/Heroin
Methamphetamine
Molly (MDMA)
None
Other
Other: Please provide more details here
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Have you had elevated Blood pressure in the past 6 months?
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No
Yes
If Yes: Please provide more details. (NA if not applicable)
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Enter your blood pressure reading taken within the last 6 months.
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Please Select
Low – Normal (120/80 or lower)
Above Normal (121/80 - 129/80)
High (130/80 - 139/89)
Higher (140/90 or greater)
Have you experienced any of the following conditions? (Select all that apply)
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Enlarged prostate
Weight gain / management
Sleep / insomnia
Hair loss
Low testosterone
Blood sugar / diabete
Acne / Rosceca / Hyperpigmentation
Joint Issues
Toe nail fungus
Pain management
None
Do you have any extra information to share with your doctor?
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No
Yes
If Yes: Please provide details you would like to share with the doctor. (NA if not applicable)
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What is your treatment preference?
*
Please Select
25mg Sildenafil, the generic version of Viagra.
50mg Sildenafil, the generic version of Viagra.
100mg Sildenafil, the generic version of Viagra.
2.5mg Daily Tadalafil, the generic version of Cialis
5mg Daily Tadalafil, the generic version of Cialis
10mg Tadalafil, the generic version of Cialis
20mg Tadalafil, the generic version of Cialis
I am not sure
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Identity Verification: Submit picture of your face
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