ED

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How Stealth Health WorksA short message from our CMO
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What is your email address?* This field is required.
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Medication
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Medication 2
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Dosage Instructions
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Quantity
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Repeats
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Please enter a promo code if you have one (Optional)
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Do you ever have a problem getting or maintaining an erection that is satisfying enough for sex?
Every time
Sometimes (More than half the time)
Occasionally
Rarely
Never
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When did your ED start?
Gradually, but has worsened over time
Suddenly, but not with a new partner
Suddenly, with a new partner
Do not recall
Other
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Please specify:
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Do you get erections?
When masturbating
When waking up
Both
Neither
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When masturbating, does your erection remain hard until orgasm or as long as desired?
It starts hard but never remains hard
Rarely remains hard
Occasionally remains hard
More than half the time remains hard (sometimes)
Always remains hard
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How often do you wake up with an erection?
Never/Rarely
Occasionally/Sometimes
Frequently/Everyday
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How is your desire to have sex?
Less than it was before
Less than it was because I know I have trouble with erections
Less and it started before I had trouble with erections
Less but I don't know which came first
Unchanged
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Have you ever been formally treated for ED or tried any medicines, vitamins, or supplements to treat it?
YESNO
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What have you tried?
Viagra (sildenafil)
Cialis (tadalafil)
Levitra (vardenafil)
Penile pump
Penile implant
Penile injections (e.g, alprostadil, bimix, trimix)
Shock wave therapy
Intraurethral therapy (MUSE)
Other
None
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Please specify:
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If you selected any of the above, how effective was it in treating your ED?
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Have you ever had any side effects from ED treatments?
YESNO
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Please explain:
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Have you had a physical exam with a healthcare provider in the past 3 years that included an examination of your genitals?
YESNO
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If yes, were there any issues noted?
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Are there any recent changes or stresses in your life that might be impacting your sexual health?
YESNO
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Do any of the following cardiovascular risk factors apply to you?
Father had a heart attack/heart disease at 55 or younger
Mother had heart attack/heart disease at 65 or younger
High Cholesterol
Diabetes
High Blood Pressure
Coronary Artery Disease
None
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In the last 2 weeks, have you experienced?
Lack of enjoyment or motivation in activities
Persistent feelings of sadness or despair
Significant nervousness or anxiety affecting daily life
Excessive worry impacting functionality at work or home
None
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Have you been diagnosed with any of the following?
HIV
Severe low blood pressure (hypotension)
Prior heart attack, heart failure, or narrowing of the arteries
Any clotting or bleeding disorder
Stroke or severe insufficiency of the autonomic nervous system
QT Prolongation (Including family history)
Sickle cell anemia, myeloma, or leukemia
Advised not to have sex (for health reasons)
Retinitis pigmentosa or anterior ischemic optic neuropathy
Idiopathic hypertrophic sub-aortic stenosis
None
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Do you have a history of the following:
Depression
Anxiety
Low testosterone
Insomnia
Limited physical activity
None
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Do any of the following apply?
Curve or bend in the penis that interferes with sex, or Peyronie's disease
Pain with erections or ejaculation
Foreskin that is too tight
Fibrous tissue in the penis (lumps or bumps under the skin that feels hard)
None
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How much exercise do you get per week?
None
1 hour or less
1-3 hours
3 hours or more
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Have you ever had any of the following:
Surgery or radiation to the prostate or pelvis
Kidney transplant or any condition affecting the kidney
Liver disease or hepatic impairment
Multiple Sclerosis (MS) or similar disease, spinal injuries or paralysis, or neurological diseases
Stomach, intestinal, or bowel ulcers
Heart arrhythmias (Abnormal heartbeat)
Congenital long QT syndrome
Acquired, congenital or developmental abnormalities or the heart (including murmurs)
None
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How often do you consume alcohol?
Please Select
Please Select
Rarely/Never
Sometimes
Frequently
Always
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How often do you consume alcohol?
Rarely/Never
Sometimes
Frequently
Daily/Always
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Have you used any of the following substances in the past six months?
Cocaine
Methamphetamine
Opioids
Cannabis
None
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Do you smoke?
YESNO
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How often do you smoke? (Packs a week, etc.)
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Are you using any nicotine replacement products to aid in quitting smoking?
YESNO
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Please specify:
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Do you have any concerns about potential side effects of ED treatments?
Huge
Large
Normal
Small
Ok
Ok
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Would you prefer a treatment that requires planning (sildenafil before activity) or an immediate approach (daily tadalafil)?
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Large
Normal
Small
Ok
Ok
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Are your requesting a specific type of treatment?
Tablets
Cream
Not sure/ no preference
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Allergies?
YESNO
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What is your allergy?
Huge
Large
Normal
Small
Ok
Ok
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Are you currently taking any medications, vitamins, herbs, or supplements?
YESNO
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Please list your medications, vitamins, herbs, and supplements here:(Name, Strength, Regimen)
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Large
Normal
Small
Ok
Ok
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Do you have any medical conditions?
YESNO
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Please list your medical conditions here:(Name, How long you've had the condition)
Huge
Large
Normal
Small
Ok
Ok
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Is there anything else you would like to share with the healthcare team?
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Large
Normal
Small
Ok
Ok
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Full Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
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Date of Birth
Year, Month, Day
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Biological Sex
Male
Female
Intersex
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
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Western Sahara
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Other
Country
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