Heads Up Questions

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 NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Birthday*

MonthDayYear
Date
Sex assigned at birth*

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.*
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. *

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? *
In the past several months, have you had any of the following: (Select all that apply)*

Chest PainPassing OutDizziness/SeizureShortness of breath or trouble breathingAbnormal heartbeatNone of the above
Have you had any surgeries? If Yes: Please list all surgeries you've had*
Is there a family history of any of the following?*

Cardiovascular diseaseUnexplained sudden deathNone 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)*

Over the past two weeks how often have felt little or no pleasure in activities you usually enjoy?*
Over the past two weeks how often have felt down, depressed, or hopeless?*
Over the past two weeks how often have felt nervous, anxious, on edge, or worrying too much?*