Lifecure – Erectile Dysfunction Intake Form

1
Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Sex at Birth* This field is required.
Male
Intersex
Prefer not to say
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Health Card Number (optional)
6
Date of Visit* This field is required.
Date
Month
Day
Year
7
Email Address* This field is required.
example@example.com
8
Phone Number* This field is required.
Please enter a valid phone number.
9
Preferred Pharmacy Name
10
Preferred Pharmacy Address
11
Preferred Pharmacy Phone
12
Preferred Pharmacy Fax
13
Medication Coverage
ODB (Government)
Trillium Drug Plan
None
Private Insurance
14
Private Insurance Provider Name* This field is required.
15
Carrier ID* This field is required.
16
Client ID* This field is required.
17
Group Number
18
Upload Insurance Card (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload a File
Cancelof
19
What best describes your concern? (Select all that apply)* This field is required.
Difficulty getting erections
Difficulty maintaining erections
Reduced firmness
Low sexual desire
Performance anxiety
Medication refill / follow-up
Other
20
How long has this been happening?* This field is required.
Less than 3 months
3–6 months
6–12 months
More than 1 year
21
Did your symptoms start suddenly or gradually?* This field is required.
Suddenly
Gradually
22
Current trend of symptoms* This field is required.
Improving
Worse
Same
23
Please select all that apply regarding erectile function:* This field is required.
Trouble getting erections
Trouble keeping erections
Erections less firm
Erections don’t last
No erections
24
Do you get morning or nighttime erections?* This field is required.
Yes
No
Not sure
25
What is the emotional impact of these symptoms?* This field is required.
None
Some
Significant
26
Are you experiencing any associated concerns? (Select all that apply)
Stress
Anxiety
Relationship issues
Low mood
Reduced libido
None
27
Please select all medical conditions that apply:* This field is required.
High blood pressure
Diabetes / prediabetes
High cholesterol
Heart disease
Stroke / TIA
Peripheral vascular disease
Obesity
Sleep apnea
Neurological disorder
Blood disorder
None
28
HORMONAL SYMPTOMS: Select all that apply
Fatigue / low energy
Reduced muscle mass
Weight gain
Low sex drive
Decreased body hair
Breast tenderness/enlargement
Known low testosterone
None
29
Chest pain with activity or sex?* This field is required.
Yes
No
30
Shortness of breath with minimal exertion?* This field is required.
Yes
No
31
Known severe heart disease?* This field is required.
Yes
No
32
Heart attack or stroke within 6 months?* This field is required.
Yes
No
33
Taking nitrate medications?* This field is required.
Yes
No
34
Severe penile pain or curvature?* This field is required.
Yes
No
35
Painful erection lasting more than 4 hours?* This field is required.
Yes
No
36
New weakness or numbness?* This field is required.
Yes
No
37
Do you smoke?* This field is required.
Yes
No
38
If yes, how much do you smoke? (per day/week)
39
How many alcoholic drinks do you have per week?
40
Do you use recreational drugs? (optional)
41
How often do you exercise?
Please Select
Please Select
Never
Rarely
1–2 times per week
3–4 times per week
5 or more times per week
42
Have you tried ED medications before?* This field is required.
No
Yes
43
Which medication(s) have you tried?* This field is required.
44
Did it help?* This field is required.
Yes
Somewhat
No
45
List all current medications* This field is required.
46
Are you taking blood thinners?* This field is required.
Yes
No
47
Do you have any medication allergies?* This field is required.
No
Yes
48
Please list medication allergies and reactions* This field is required.
49
Have you started any new medications recently?* This field is required.
Yes
No
50
Please select all surgical/urologic history that apply:
Prostate cancer / surgery
Pelvic surgery
Radiation
Testicular problems
None
51
Is there anything else we should know?
52
Upload bloodwork if available (optional)
Drag and drop files here
Select files to upload
Max. file size: 10.0MB
Upload a File
Cancelof
53
I confirm that the information provided is accurate and consent to assessment and treatment by Lifecure.* This field is required.
Should be Empty: