Erectile Dysfunction Visit
  • Date of Birth*
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  • Format: (000) 000-0000.
  • What was your gender at birth?*

  • You should NOT use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:

    • Severe or unusual chest pain
    • Severe shortness of breath
    • Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
    • Thoughts of harming yourself or others
  • ARE YOU EXPERIENCING AN EMERGENCY? IF YOU ARE EXPERIENCING AN EMERGENCY, CALL 911 OR GO TO AN EMERGENCY ROOM IMMEDIATELY.*
  • Please tell us the reason for your visit today.*
  • Which of the following do you take?*
  • Has your medication been effective?*
  • When did your erectile dysfunction symptoms start?*
  • How did your symptoms begin?*
  • When do you experience erections? (Select ALL that apply)*


  • Premature ejaculation is when ejaculation happens within a short time of entering a partner.

  • Do you have premature ejaculation?*

  • To better understand the severity of the symptoms being experienced, we are going to ask 5 questions from a commonly used guideline for the evaluation of erectile dysfunction.

    Over the past 6 months:

  • Please rate your confidence of getting and keeping an erection:*
  • For erections caused by sexual stimulation, how often were they hard enough to enter a partner?*
  • During sexual intercourse, how often were you able to maintain an erection after entering a partner?*
  • During sexual intercourse, how difficult was it to maintain an erection to completion of intercourse?*
  • When sexual intercourse was attempted, how often was it satisfactory?*
  • Has a provider previously provided a prescription to treat erectile dysfunction?*
  • Was the medication helpful?*
  • Do you have a medication preference?*
  • Which erectile dysfunction medication is preferred? While preference will be taken into consideration, the provider will prescribe the medication best suited for you.*

  • MEDICAL HISTORY

  • When was your last physical evaluation with a provider?*
  • Do you have a history of any of the following genital conditions? (Select ALL that apply)*
  • Do you have a history of any of the following cardiac conditions? (Select ALL that apply)*
  • Do you have a history of any of the following? (Select ALL that apply)*
  • Do any of the following immunosuppressive treatments or conditions apply to you? (Select ALL that apply)*
  • Have you had a blood pressure reading taken in the past month?*

  • It is essential to provide a recent and accurate blood pressure reading. People with high blood pressure are at increased risk of complications when taking certain medications for erectile dysfunction. Blood pressure can be checked for free at most pharmacies. 

    After getting your blood pressure reading, please come back to this visit and enter the blood pressure. 

  • A blood pressure reading contains 2 numbers written like a fraction (e.g., 120/80; read as "120 over 80"). The higher number (120) is the systolic blood pressure. The lower number (80) is the diastolic blood pressure. 

    Please enter the systolic and diastolic blood pressure readings below:

  • Do you smoke, use smokeless tobacco, vape, or use other e-cigarette products?*
  • Are you interested in discussing treatments for smoking/tobacco cessation?*
  • Do you have any medication allergies?*
  • Are you currently taking any medications?*

  • PHARMACY INFORMATION

    Please choose where you would like your prescription sent
  • Would you like to add any additional information or questions for the provider to see?*

  • My Products*

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