Infini Pulse Intake Form

1
Full Name* This field is required.
First Name
Last Name
2
Email* This field is required.What is your best email address?
example@example.com
3
How did you hear about us?* This field is required.
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Please Select
Internet Search
iDrip Therapy
Referred
How did you hear about us?
If referred - please let us know from who or where ----- If Internet Search - What did you search for?
4
In your own words, tell us about your reason for seeking consultation, service, and/or treatment* This field is required.
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5
Address* This field is required.We Currently Serve Patients in ARIZONA, FLORIDA, & WASHINGTON STATE Only
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
6
What is your biological sex?* This field is required.
Female
Male
7
What is your date of birth?* This field is required.
Date
Year
Month
Day
8
What is your Phone Number* This field is required.
Area Code
Phone Number
9
What is your weight and height?* This field is required.
10
What is your blood pressure?* This field is required.Normally, what is your blood pressure?
ex: 120/80
11
How often do you use tobacco products?* This field is required.
Not very often
A couple of times per week
Daily
Never
12
How often do you use alcohol products?* This field is required.
Not very often
A couple of times per week
Daily
Never
13
How often do you use caffeine products?* This field is required.
Not very often
A couple of times per week
Daily
Never
14
Select the items that you are allergic to* This field is required.Select “None” if not applicable
None
Food
Pet
Seasonal
Dye Allergies
Aspirin
Penicillin
Nitrate
Codeine
Morphine
Sulfa Drug
Other Allergy
15
You selected "Other Allergy " - Please Elaborate* This field is required.
16
Do you use any of the following over-the-counter-medications?* This field is required.Select “None” if not applicable
None
Aspirin
Ibuprofen
Naproxen
Ketaprofen
Pain Reliever
Acetaminophen
Diet Aids
Laxatives
Anti-Diarheal
Acid Blocker
Antacid
Decongestant
Anti Histamine
Cough Suppressant
Sleep Aids
Other OTC Medication
17
You selected "Other OTC Medication" - Please Elaborate* This field is required.
18
Do you use any of the following medical conditions?* This field is required.Select “None” if not applicable
None
Allergies
Arthritis
Back Problems/ Injuries
Skin Disorder
Cancer
Erectile Dysfunction
Hormone Imbalance
Anxiety
Depression
Thyroid
Epilepsy
Diabetes
Migraines
Heart Attack
Heart Disease
Hypertension
Cholesterol Problems
Blood Clotting Issue
Eye Disease
Ulcers
Lung Issues
Kidney Issues
Other Condition
19
You selected "Other Condition" - Please Elaborate* This field is required.
20
Are you currently taking any other medications, supplements, or vitamins?* This field is required.
YESNO
21
Please list all medications you are currently taking* This field is required.
22
Have any of your immediate family (parents or siblings) had a history of heart disease?* This field is required.
YESNO
23
Who in relation to you had a history of heart disease?* This field is required.
Mother
Father
Brother
Sister
24
Have any of your immediate family (parents or siblings) had a history of high blood pressure?* This field is required.
YESNO
25
Who in relation to you had a history of high blood pressure?* This field is required.
Mother
Father
Brother
Sister
26
Have any of your immediate family (parents or siblings) had a history of diabetes?* This field is required.
YESNO
27
Who in relation to you had a history of diabetes?* This field is required.
Mother
Father
Brother
Sister
28
Have any of your immediate family (parents or siblings) had a history of arthritis?* This field is required.
YESNO
29
Who in relation to you had a history of arthritis?* This field is required.
Mother
Father
Brother
Sister
30
Have any of your immediate family (parents or siblings) had a history of skin disorders?* This field is required.
YESNO
31
Who in relation to you had a history of skin disorders?* This field is required.
Mother
Father
Brother
Sister
32
Have any of your immediate family (parents or siblings) had a history of cancer?* This field is required.
YESNO
33
Who in relation to you had a history of cancer?* This field is required.
Mother
Father
Brother
Sister
34
Do you have a primary care physician?* This field is required.
YESNO
35
Have you had hormone therapy before?* This field is required.
YESNO
36
You've indicated that you've had hormone therapy. Can you elaborate on that?* This field is required.
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Ok
37
Have you been diagnosed with prostate cancer?* This field is required.
YESNO
38
You've indicated that you've had prostate cancer. Can you elaborate on that?* This field is required.
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Small
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Ok
39
Have you been diagnosed with prostate enlargement?* This field is required.
YESNO
40
You've indicated that you've had prostate enlargement. Can you elaborate on that?* This field is required.
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Large
Normal
Small
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Ok
41
Have you been diagnosed with testicular cancer?* This field is required.
YESNO
42
You've indicated that you've had testicular cancer. Can you elaborate on that?* This field is required.
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Small
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Ok
43
Have you ever had testicular pain?* This field is required.
YESNO
44
You've indicated that you've had testicular pain. Can you elaborate on that?* This field is required.
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Ok
45
Have you ever had erectile dysfunction?* This field is required.
YESNO
46
You've indicated that you've had erectile dysfunction. Can you elaborate on that?* This field is required.
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Ok
47
Do you have decreased libido?* This field is required.
YESNO
48
You've indicated that you've had decreased libido. Can you elaborate on that?* This field is required.
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Small
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Ok
49
Do you have decreased energy?* This field is required.
YESNO
50
You've indicated that you've had decreased energy. Can you elaborate on that?* This field is required.
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Small
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Ok
51
Have you ever had gynecomastia?* This field is required.Gynecomastia (Breast Enlargement)
YESNO
52
You've indicated that you've had gynecomastia (breast enlargement). Can you elaborate on that?* This field is required.
Huge
Large
Normal
Small
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Ok
53
Have you had loss in muscle mass?* This field is required.
YESNO
54
You've indicated that you've had loss in muscle mass. Can you elaborate on that?* This field is required.
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Small
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Ok
55
Have you had any weight gain?* This field is required.
YESNO
56
You've indicated that you've had weight gain. Can you elaborate on that?* This field is required.
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Small
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Ok
57
Have you had decreased motivation?* This field is required.
YESNO
58
You've indicated that you've had decreased motivation. Can you elaborate on that?* This field is required.
Huge
Large
Normal
Small
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Ok
59
Have you experienced an inability to concentrate?* This field is required.
YESNO
60
You've indicated that you've experienced an inability to concentrate. Can you elaborate on that?* This field is required.
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Large
Normal
Small
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Ok
61
Have you had any depressive episodes?* This field is required.
YESNO
62
You've indicated that you've depressive episodes. Can you elaborate on that?* This field is required.
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Small
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Ok
63
For compliance purposes, we need to verify your identityPlease take a picture/upload a picture of the FRONT of your drivers license.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
64
For compliance purposes, we need to verify your identityPlease take a picture/upload a picture of the BACK of your drivers license.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
65
If approved for our program, where would you like your medicine shipped?If different from Home 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
66
Infini Pulse Terms & Conditions* This field is required.
67
Infini Pulse Terms & Conditions Signature* This field is required.
Clear
68
Infini Pulse Privacy Policy* This field is required.
69
Infini Pulse Privacy Policy Signature* This field is required.
Clear
70
Continue to Peptide Specific Enrollment
YESNO
71
Are you an athlete in a sport that subscribes to the WADA world Anti-Doping Code?* This field is required.
YESNO
72
What WADA-affiliated sport do you play?* This field is required.
73
Which goals reflect your interests* This field is required.Check all that apply
Anti-Aging
Muscle Building
Fat loss/ Weight loss
Safe Enhanced Tanning
Injury Repair
Increased Libido
Hair Loss Solutions
Sleep Improvement
74
Do you experience night sweats?* This field is required.
YESNO
75
Do you know the reason for your night sweats?* This field is required.Please elaborate with detail
76
Do you experience fevers?* This field is required.
YESNO
77
Do you know the reason for your fevers?* This field is required.Please elaborate with detail
78
Do you experience reduced appetite?* This field is required.
YESNO
79
Do you know the reason for your reduced appetite?* This field is required.Please elaborate with detail
80
Do you experience severe fatigue?* This field is required.
YESNO
81
Do you know the reason for your severe fatigue?* This field is required.Please elaborate with detail
82
Have you experienced unexplained weight loss?* This field is required.
YESNO
83
Do you know the reason for your unexplained weight loss?* This field is required.Please elaborate with detail
84
Do you have any lumps ?* This field is required.e.g. breast, armpit, skin...
YESNO
85
Do you know the reason for these lumps?* This field is required.Please elaborate with detail
86
Do you have uncontrolled diabetes mellitus?* This field is required.
YESNO
87
You stated you have uncontrolled diabetes* This field is required.Please answer the following questions to the best of your ability - please enter N/A if something does not apply
88
Do you have uncontrolled thyroid disease?* This field is required.
YESNO
89
You stated you have uncontrolled thyroid disease* This field is required.Please answer the following questions to the best of your ability - please enter N/A if something does not apply
90
Do you have uncontrolled heart disease?* This field is required.
YESNO
91
You stated you have uncontrolled heart disease* This field is required.Please answer the following questions to the best of your ability - please enter N/A if something does not apply
92
Do you have benign intracranial hypertension?* This field is required.
YESNO
93
You stated you have benign intracranial hypertension* This field is required.Please answer the following questions to the best of your ability - please enter N/A if something does not apply
94
Do you have proliferative or pre-proliferative diabetic retinopathy?* This field is required.
YESNO
95
You stated you have proliferative or pre-proliferative diabetic retinopathy* This field is required.Please answer the following questions to the best of your ability - please enter N/A if something does not apply
96
Do you have any form of cancer?* This field is required.
YESNO
97
You stated you have a form of cancer* This field is required.Please answer the following questions to the best of your ability - please enter N/A if something does not apply
98
Do you have any current medical or surgical problems?* This field is required.
YESNO
99
You stated that you have a current medical or surgical problem, please elaborate:* This field is required.
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Small
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Ok
100
Are you currently pregnant or breastfeeding?* This field is required.
YESNO
101
Continue to Sexual Wellness Program EnrollmentIf you are interested in our Erectile Dysfunction Program, please select YES
YESNO
102
In your own words, tell us about your reason for seeking treatment* This field is required.
103
Have you ever been treated for ED? This includes medications prescribed or purchased over the counter, and any other treatments.* This field is required.
None
Viagra
Cialis
Levitra
Other
104
What dose of Viagra, Cialis, Levitra, or Other have you used?* This field is required.Type N/A if you do not recall specifics
105
Did you experience any serious side effects that made you stop?* This field is required.
No, I never had any side effects
No, the side effects did no make me stop
Yes
106
What side effects did you experience?* This field is required.
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Ok
107
Do you ever have a problem getting or maintaining an erection that is satisfying enough for sex?* This field is required.
yes, every time
yes, more than half of the time
yes, on occasion
yes, but rarely
I have never have had a problem getting an erection or maintaining it for as long as I want
108
How did your ED begin? Select the one that best describes your ED.* This field is required.
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
109
ED can be caused by underlying health problems. Sometimes, it is the result of our lifestyle habits.* This field is required.
I do not get as much exercise as I should
I do not eat healthy as much as I should
Smoke tobacco
I drink more than I should (greater than 2 drinks per day)
I do not sleep as much as I should
I’m 20+ lbs overweight
110
Do you get erections when
when masturbating
when you wake up
111
When masturbating, does your erection remain hard until orgasm or as long as you would like?* This field is required.
No, it starts hard but never remains hard
Yes, but only rarely
Yes, on occasion
Yes, more than half of the time
Yes, always
112
How often do you wake up with an erection?* This field is required.
Rarely
Sometimes
Every time
113
Have you had a physical exam with a healthcare provider in the past five years, including an examination of the genitals (penis, testis, and groin)? If not, we recommend visiting a healthcare provider before using our services.* This field is required.
Yes, it was normal
Yes, but there were issues
No
114
You stated that there were issues in your exam, please explain your exam in more detail * This field is required.
Huge
Large
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Small
Ok
Ok
115
Do you have any of the following conditions? Select all that apply. Some cases of ED are best managed by a healthcare provider you visit in person.* This field is required.
Not Applicable
For health reasons or any others, you have been advised not to have sex.
HIV
Severe low blood pressure
Prior heart attack
Clotting or bleeding disorder
Stroke or severe insufficiency of the autonomic nervous system
Any personal or family history of QT prolongation
Sickle cell anaemia, myeloma, or leukemia
Retinitis pigementosa or anterior ischemic optic neuropathy
Idiopathic hypertrophic subaortic stenosis
Surgery or radiation to the prostrate or pelvis
Kidney transplant or any condition affecting the kidney
Liver disease
Multiple sclerosis (MS) or similar disease, spinal injuries or paralysis, or neurological disease
Stomach, intestinal, or bowel ulcers
Heart arrhythmias, which is an abnormal beating of the heart
Any acquired, congential or developmental abnormalities of the heart including heart murmurs
116
Please tell us more about your HIV and current treatment. Do you know your CD4 count? What was your last viral load and when was it measured? And are you currently taking any medication for HIV? If so, what medications?* This field is required.
117
Please tell us more about your heart attack. When did it occur? How are you currently being treated?* This field is required.
118
Can you tell us more about your surgery or radiation for your prostate or pelvis? For what condition did you receive the treatment? What was the procedure? When did it occur? Are you currently receiving any treatment for it?* This field is required.
119
Can you please tell us more about your kidney transplant or condition? What was the diagnosis and are you currently receiving treatment?* This field is required.
120
Can you please provide more information regarding your liver disease? Specifically, what is the diagnosis and its status? Is it routinely monitored? Please explain your current treatment and any other information you think your physician would find helpful* This field is required.
121
You had indicated that you have "Multiple sclerosis (MS) or similar disease, spinal injuries or paralysis, or neurological diseases." Have you ever had low blood pressure or labile blood pressure (blood pressure that swings between being high and low)? Can you please elaborate on which condition and any treatment you are receiving?* This field is required.
122
You made note that you have had ulcers in the past. Have you sought treatment for this? If so, what kind of treatment did you receive? Have the ulcer(s) healed? Please explain more.* This field is required.
123
Can you tell us about your heart arrhythmias? When was this detected and did you undergo any treatment? Are you undergoing treatment presently? If so, what is the current treatment?* This field is required.
124
Can you tell us more about your heart arrhythmia or murmur? Have you sought treatment for this? If so, what kind of treatment did you receive? Please explain more. * This field is required.
125
ED is often an early sign of hardening of the arteries, which may cause difficulties with erections even before it affects the heart and causes heart attacks. Do you have any of the following cardiovascular symptoms/risk factors?* This field is required.
Not Applicable
Abnormal heart beats: rapid, irregular, or unusually slow (slower than 60 beats/minute)
Chest pain (angina) or shortness of breath while walking up 2 flights of stairs
Any episodes of unexplained, lightheadness, fainting, or dizziness
Other than regular muscular soreness with exercise, cramping or pain in the thighs (claudication)
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
High blood pressure
126
Please explain your abnormal heart beats in more detail. Have you sought treatment for this? If so, what kind of treatment did you receive? Please explain more.* This field is required.
127
Please explain your episodes of fainting, light-headedness, or dizziness. Have you sought treatment for this? If so, what kind of treatment did you receive? Please explain more.* This field is required.
128
Can you tell me more about the pain in your legs? For example, where do you get pain and what type and intensity of activity (if any) causes the pain? What makes the pain better?* This field is required.
129
Are you currently on any medication for your high cholesterol? If so, what is the medication, dose, and frequency? Also, do you remember your total cholesterol, LDL, HDL, triglycerides?* This field is required.
130
Are you on any medications for your Diabetes? What is your average daily blood sugar? What was your last HgA1C and how long ago was it?* This field is required.
131
You mentioned you have high blood pressure. How is it currently being treated? Are you taking any medications? If so, what is the medication, dose, and frequency?* This field is required.
132
Death can result if ED meds are used in conjunction with other medications. Please, be accurate. I use or have used...* This field is required.
Not Applicable
Medicine containing nitrates
Any medication called an alpha blocker. They are used high blood pressure or prostate problems. Including Cardura (doxazosin), Coreg (carvedilol), Flomax (tamsulosin), Hytrin (terazosin), Minipress (prazosin), Rapaflo (silodosin), Regitine or Oraverse (phentolamine), Trandate (labetalol), Uraxatral (alfuzosin)
Nitroglycerin in any form—as a spray, tablet, patch or ointment! Names include: Deponit, Minitran, Nitrek, Nitro-Bid, Nitrocot, Nitrodisc, Nitro-Dur, Nitrogard, Nitroglyn, Nitrol, Nitrolingua, Nitrolingual, NitroMist, Nitrong, Nitronol, Nitro-Par, Nitroquick, Nitrostat, Nitrotab, NitroTime, Transdermal-Nitro
Sildenafil (Revatio) used to treat pulmonary hypertension
Isosorbide mononitrate or Isosorbide dinitrate. Also includes (Dilatrate, Dilatrate–SR, Imdur, Ismo, Isordil, Monoket, Sorbitrate)
Adempas (Riociquat), which is used to treat pulmonary hypertension
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Please explain your use of nitrates. How frequently? When was the last time? * This field is required.
134
Please tell us more about your history of alpha blockers. What is the medication, dose, and frequency? Also, have you been on it for some time and have you tolerated it well? (i.e., your blood pressure has remained stable and you have had no worrisome side effects such as dizziness or faintness)? * This field is required.
135
Can you please expand on your use of “Nitroglycerin in any form”. What specifically have you used in the past, what was the indication and do you presently use (even occasionally) or anticipate using this in the future?* This field is required.
136
Death can result if ED meds are used in conjunction with recreational drugs. Have you, or are you currently using any of the following recreational drugs?* This field is required.
Not Applicable
Poppers or Rush
Amly Nitrate or Butyl Nitrate
Cocaine
Molly (MDMA,/ Ecstasy)
Other
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Please explain your use of Poppers or Rush. How frequently? When was the last time?* This field is required.
138
Please explain your use of Amyl Nitrate or Butyl Nitrate. How frequently? When was the last time? * This field is required.
139
Please explain your use of cocaine. How frequently? When was the last time? * This field is required.
140
Please explain your use of Molly (MDMA, ecstasy). How frequently? When was the last time? * This field is required.
141
Please explain what other recreational drugs you use. How frequently? When was the last time? * This field is required.
142
Do you have any of these conditions? Select all that apply.* This field is required.
Not Applicable
A marked curve or bend in the penis, that interferes with sex or peyronie’s disease
Pain with erections or with ejaculations
A foreskin that is too tight
Fibrous tissue with the penis(lumps and bumps that feel hard)
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Does the mark or curve prevent you from having sex? Is it painful? Have you sought treatment for this? If so, what kind of treatment did you receive? Please explain more. * This field is required.
144
Can you please explain more about the pain you experience when you have an erection or when you ejaculate? * This field is required.
145
Does your tight foreskin cause pain when you have an erection? Does this interfere with sex? Are you able to pull your foreskin back and forth over the head of your penis? Have you received treatment for this condition? If so, what kind of treatment did you receive? Please explain in more detail. * This field is required.
146
Have you been evaluated for the fibrous tissue in the penis by a physician? What was the diagnosis? Have you received treatment for this condition? If so, what kind of treatment? * This field is required.
147
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