What's your Email?
Please provide a valid email, so we can send you important prescription information.
I am a male:
Yes
No
Today I am starting:
E.D. Treatment
Hair Loss Treatment
P.E. Treatment
How often do you experience Erectile Dysfunction?
Every Time
Sometimes
Rarely
Never
Where are you experiencing hair loss?
Hairline
Top of head
Hair loss due to chemotherapy
Do you experience any of the following:
Burning or pain on scalp
Patches of rough skin or scarring
Pustules or crusting
None of the above
Which of these do you experience:
(Select all that apply)
Difficulty Achieving Erection
Difficulty Maintaining Erection
Premature Ejaculation
Name
Phone
Please enter your date of birth
(MM/DD/YYYY):
When do you have erections?
When waking up
When masturbating
When waking up and when masturbating
Never
Have you ever been treated for P.E. ?
Yes
No
How often do you ejaculate sooner than desired?
Every time
Occasionally
Rarely
Never
Typically, how long does it take for you to ejaculate upon sexual stimulation?
Less than 1 min
1-5 min
5-10 min
More than 10 min
How long has premature ejaculation been an issue?
Less than 1 month
1-6 months
6-12 months
More than a year
When was your last physical?
Less than 1 Year Ago
1-2 Years Ago
2-3 Years Ago
More than 3 Years Ago
Do you have any medical conditions?
Yes
No
What medical condition(s) do you have?
Are you currently taking any medications or supplements?
Yes
No
Please list your medications or supplements and reason for taking them.
Do you have a family history of mental illness?
Yes
No
Please list the conditions and your relation to the family member.
Do you experience anxiety or nervousness.
Yes
No
How often do you have these feelings?
Every day
Occasionally
Rarely
Do you feel depressed or hopeless, or have little interest in doing things?
Yes
No
How often do you have these feelings?
Every day
Occasionally
Rarely
Are you currently taking any medications that contain nitrates, such as Nitrolycerin, Nitrogard, Isordil, Imdur, Nipride?
Yes
No
ALERT: If you are taking any form of Nitrates, please see your doctor for help with your E.D. treatment.
E.D. medications CANNOT be taken with nitrates.
Do you have allergies or reactions to certain medicines?
Yes
No
Please explain
Do you have any heart conditions?
Yes
No
Please explain.
Have you recently experienced any difficulty breathing or chest pains?
Yes
No
Please explain.
Have you had any surgeries or hospitalizations?
Yes
No
Please tell us when and the reason(s) for hospitalizations or surgeries.
Have you ever been diagnosed with High Blood Pressure?
Yes
No
If "Yes", then please select one of the following:
My blood pressure is under control with medications
I do not take medications for my high blood pressure
What medications are you taking for your high blood pressure?
Can you walk for 30 minutes without any problems?
Yes
No
Do you maintain an active lifestyle?
(Sports, hiking, fitness, swimming, walking, bicycling)
Yes
No
Do you or have you used any of these the last 6 months:
(Please select as many as apply)
Cigarettes
Marijuana
Poppers or Rush
Cocaine or Crack
Nitrates
None
On Average, how much alcohol do you consume in a week?
I don't drink
Less than 5 drinks per week
Between 5-10 drinks per week
More than 10 drinks per week
Any questions or messages you would like to ask our physician?
I agree to the
Terms & Conditions,
Privacy
, and I consent to a
Telehealth
visit.
Yes
COMPLETE & CHECKOUT
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