Tell Us About Yourself
In order to receive your prescription, please answer these questions for our physician:
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1. Personal Health Info
On a scale from 1 to 5, how satisfied have you been with your sex life in the past six months?
*
Please Select
1 (Not at all)
2 (A little bit)
3 (Somewhat)
4 (Quite a bit)
5 (Very)
How did your ED begin? Select the one that best describes your ED.
*
Please Select
Gradually but has worsened over time
Suddenly, but not with a new partner
Suddenly, with a new partner
I do not recall how it began
On a scale from 1 to 5, how would you rate your partner’s satisfaction with your sex life together?
*
Please Select
1 (Not at all)
2 (A little bit)
3 (Somewhat)
4 (Quite a bit)
5 (Very)
I don’t know, or this question doesn’t apply to me
How satisfied have you been with the hardness of your erections over the past six months?
*
Please Select
1 (Not at all)
2 (A little bit)
3 (Somewhat)
4 (Quite a bit)
5 (Very)
I don’t know, or this question doesn’t apply to me
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1. Personal Health Info
On a scale from 1 to 5, how would you rate your self-confidence over the past six months?
*
Please Select
1 (Very low)
2 (Low)
3 (Neutral)
4 (High)
5 (Very high)
How satisfied have you been with your ability to get an erection whenever you wanted over the past six months, in general?
*
Please Select
1 (Not at all)
2 (A little bit)
3 (Somewhat)
4 (Quite a bit)
5 (Very)
I don’t know, or this question doesn’t apply to me
On a scale from 1 to 5, how would you rate the way you feel about your body over the past six months?
*
Please Select
1 (Very poor)
2 (Poor)
3 (Fair)
4 (Good)
5 (Very good)
Have you ever been formally treated for ED or tried any medicines, vitamins, or supplements to treat it?
*
Please Select
Yes
No
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1. Personal Health Info
Do you ever have a problem ejaculating sooner than you or your partner would like?*
*
Please Select
Yes, I always ejaculate too soon
Yes, More than half the time I ejaculate too soon
Yes, less than half the time I ejaculate too soon
No, I rarely ejaculate too soon
Have you been diagnosed with or treated for high or low blood pressure?
*
Please Select
No
Yes, I have been diagnosed or treated for high blood pressure
Yes, I have been diagnosed with or treated for low blood pressure
I’m not sure
Do you have any medical conditions or a history of prior surgeries?
*
Please Select
Yes
No
Do any of the following cardiovascular risk factors apply to you?
*
Please Select
High cholesterol
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
Diabetes
None apply to me
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1. Personal Health Info
In the last 2 weeks, have you been bothered by any of the following?
*
Please Select
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Feeling nervous, anxious, or on edge (enough that it impairs your ability to function at work or at home)
Worrying too much about different things (enough that it impairs your ability to function at work or at home)
No, I have not been bothered by feeling down, anxious, nervous, etc. in the last 2 weeks
Do you currently have, or have you ever experienced, any of the following?
*
Please Select
HIV
A prior heart attack, heart failure, or narrowing of the arteries
Severe low blood pressure or blood pressure that changes widely
An abnormal thickening of the wall of the heart (called “hypertrophic cardiomyopathy”)
A specific change to the electrical signals that make your heart beat, called “QT prolongation”
A family history of QT prolongation
Any clotting or bleeding disorder
Stroke or bleeding from your brain
A blood cell disorder, such as sickle cell disease, myeloma, lymphoma, or leukemia
A rare genetic disorder called “retinitis pigmentosa”, which typically causes gradual changes to your vision
A sudden loss of vision caused by loss of blood flow to your eye (called “anterior ischemic optic neuropathy”)
A rare disorder called “pulmonary hypertension”, which specifically affects blood vessels that supply the lungs (this is NOT the same as the more common diagnoses of high blood pressure)
For health reasons, or any reason, you have been advised not to have sex
No, I have never had any of these conditions
Do you have any of these conditions?
*
Please Select
A marked curve or bend in the penis that interferes with sex, or Peyronie’s disease
Pain with erections or with ejaculation
A foreskin that is too tight
Fibrous tissue in the penis (lumps and bumps under the skin that feels hard)
No, I do not have any of these conditions
Do you have any of the following symptoms related to your heart or blood vessels?
*
Please Select
Abnormal heartbeats - too fast, too slow (fewer than 60 beats per minute), or an irregular heart rhythm
Pain in your chest or trouble breathing that get worse with physical activity, such as walking up 2 flights of stairs
Episodes of unexplained fainting, lightheadedness, or dizziness
Cramping or pain in the calves or thighs with exercise (claudication)
None apply to me
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1. Personal Health Info
Do you currently have, or have you ever experienced, any of the following? Select all that apply.
*
Please Select
Surgery or radiation to the prostate or pelvis
Kidney transplant or any condition affecting the kidney
Liver disease
Multiple sclerosis (MS) or similar disease, spinal injuries or paralysis, or neurological diseases
Heart arrhythmias, which is an abnormal beating of the heart
Any acquired, congenital or developmental abnormalities of the heart including heart murmurs
No, I have never had any of these conditions
Which of the following apply to you?
*
Please Select
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
None of these apply to me
Do you currently use, or have an active prescription for, any of the following?
*
Please Select
Absolutely any medicine containing nitrates
Any ALPHA blocker, which is NOT the same as a beta blocker; Examples of ALPHA blockers include Flomax (tamsulosin), Cardura (doxazosin), and minipress (prazosin)
Nitroglycerin in any form — as a spray, tablet, patch, or ointment
Supplements that boost nitric oxide
Monoket (isosorbide mononitrate), Bidil, or Isordil (isosorbide dinitrate), which are commonly prescribed to prevent chest pain caused by heart disease.
Adempas (riociguat)
None that apply to me
Have you used any of the following recreational drugs in the past 6 months?
*
Please Select
Methamphetamines or amphetamines (crystal meth)
Poppers or Rush
Amyl Nitrate or Butyl Nitrate
Cocaine
Molly (MDMA, Ecstasy)
Other
No, I have not used any recreational drugs in the last 6 months
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1. Personal Health Info
Knowing your race and/or ethnic background helps us work toward improving equally accessible, high quality care for everyone on our platform.
*
Please Select
White
Hispanic or Latino
Black or African American
Native American or American Indian
Asian / Pacific Islander
Other
I prefer not to answer
Do you have any allergies to prescription or over-the-counter medicines, herbs, vitamins, supplements, food, dyes, or anything else? Our clinicians use this information in determining a safe and effective treatment.
*
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Do you take any prescriptions and over-the-counter medications, herbs, minerals, inhalers, injections, and medication implants or patches? Do not include any medications that Simple RX is prescribing. Our clinicians use this information in determining a safe and effective treatment.
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What is your current dosage and supply?
*
Please Select
1 month supply 25mg
1 month supply 50mg
1 month supply 100mg
3 month supply 25mg
3 month supply 50mg
3 month supply 100mg
6 month supply 25mg
6 month supply 50mg
6 month supply 100mg
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2. Information for Pharmacy
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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3. Contact Information
Name
*
First Name
Last Name
Best Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
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