ED

1
Please enter a promo code if you have one (Optional)
2
Do you ever have a problem getting or maintaining an erection that is satisfying enough for sex?* This field is required.
Every time
Sometimes (more than half the time)
Occasionally
Rarely
Never
3
Have you ever been formally treated for ED or tried any medicines, vitamins, or supplements to treat it?* This field is required.
YESNO
4
What medication have you tried and was it effective for you?* This field is required.
5
If you selected any of the above, how effective was it in treating your ED?* This field is required.
Very Effective
Mildly Effective
Not effective, I am looking for something different or stronger
6
Have you had an allergic reaction of major side effect to any medication?* This field is required.
YESNO
7
Please describe what happened: * This field is required.
8
Have you had a physical exam with a healthcare provider in the past 3 years?* This field is required.
YESNO
9
Do any of the following cardiovascular risk factors apply to you?* This field is required.
History of heart attack or stroke
Unstable angina
Heart failure
Uncontrolled high blood pressure
Significant arrhythmia
Valvular disease
None of the above apply to me
10
Have you been diagnosed with any of the following?* This field is required.
Severe liver disease
End-stage kidney disease or on dialysis
Inherited retinal disorders (retinitis pigmentosa)
Blood disorders such as: Sickle cell, Leukemia, or mutliple myeloma
Peyronie’s disease
Depression or anxiety
Diabetes
History or prostate surgery
None of the above apply to me
11
Do you have any medical conditions that were not listed?* This field is required.
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Large
Normal
Small
Ok
Ok
12
Are you taking any of the following medications?* This field is required.
Blood thinners such as: warfarin (Coumadin), rivaroxaban (Xarelto), dabigatran (Pradaxa), apixaban (Eliquis), or clopidogrel (Plavix)
Nitrates such as: Nitroglycerin (tablets, spray, patch, or ointment), Isosorbide mononitrate (Imdur), or Isosorbide dinitrate (Isordil)
Genvoya, Stribild, Symtuza, Prezcobix and Evotaz, Ritonivir used for HIV
None of the above
13
Please list your medications, vitamins, and supplements here:* This field is required.
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Large
Normal
Small
Ok
Ok
14
Have you used any of the following substances in the past six months?* This field is required.
Recreational Nitrates such as "Poppers"
Cocaine
Methamphetamine
MDMA / Ecstasy
None of the above
15
Is there anything else you would like to share with the healthcare team?* This field is required.
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Large
Normal
Small
Ok
Ok
16
Are you looking for a specific product?* This field is required.
Sildenafil
Tadalafil
A combination product
Prefer a recommendation from medical team
17
Terms and Conditions* This field is required.
18
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