Get Started Here’s how it works! Answer the following questions about your health. Your answers will be sent to the doctor for review. Your doctor will follow up. Name First Last Email SexMaleFemaleBirthdateZip CodeConsent I agree to the privacy policy.SexMaleFemaleBirthdateZip CodeDo you ever have a problem getting or maintaining an erection that is satisfying enough for sex?Yes, every timeYes, more than half the timeYes, on occassionYes, but rarelyNo, I never have a problemHow did your E.D. begin?Gradually, but it has worsened over timeSuddenly, but not with a new partnerSuddenly, with a new partnerI do not recallDo you get erections...when masturbatingwhen you wake upneitherHow often do you wake up with an erection?RarelySometimesAlwaysWhich of the following describes your desire to have sex?Less than it wasLess than it was because I have trouble with erectionsLess and it started before I had trouble with erectionsLess but I don't know which came firstUnchangedHave you tried any medicines, vitamins or supplements, or been formally treated for E.D.?YesNoHave you had a physical exam with a healthcare provider in the past 3 years that included an exam of your genitals?Yes, it was normalYes, there were issuesNo, I haven't in the past 3 yearsHave you had your blood pressure measured in the past 6 months?No, I don't know my blood pressureyes, and I know my blood pressure (entered below)Blood Pressure (if known)Please list all current medications, vitamins and dietary supplements you are takingDo you have any allergies?NoYes (enter below)Allergies (if applicable)Do you have any medical conditions or prior surgeries?NoYes (enter below)Medical Conditions (if applicable)Do any of the following cardiovascular risk factors apply to you?High CholestrolMy father had a heart attack or heart disease at 55 years or youngerMy mother had a heart attack or heart disease at 65 years or youngerDiabetesHigh Blood PressureNone apply to meIn the last 2 weeks, have you been troubled by any of the following?little interest or pleasure in doing anythingfeeling down, depressed or hopelessfeeling nervous, anxious or on edgeworrying too much about different thingsno, I have not felt downDo you have any of the following conditions?for health reasons, or any other reason, have you been advised not to have sex?HIVseverely low blood pressurea prior heart attacka clotting or bleeding disorderstrokesickle cell anemia, myeloma or leukemiaretinits pigmentosaidiopathic hypertrophic subaortic stenosisNo, I do not have these conditionsDo you have any of these conditions?a marked curve or bend in your penispain with erections or ejaculationsa foreskin that is too tightfibrous tissue in your penisno, I do not have any of these conditionsDo you have now, or have ever had, any of the following conditions?surgery or radiation to prostate or pelviskidney transplant or kidney conditionliver diseasemultiple sclerosisstomach, intestinal or bowel ulcersheart arrhythmiasany acquired or congential or developmental abnormalities of the heartnone apply to meDo you have any of the following cardiovascular symptoms?abnormal heart beatschest pain or shortness of breathepisodes of unexplained fainting, lightheadedness or dizzinesscramping or pain in calves or thighs with exercisenone apply to meDo you currently use, or have used in the past, any of the following medications?Absolutely any medications containing nitrateAny alpha blockersNitroglycerinSildenafil (Reiatio)Isosorbide Monoitrate or Isosorbide DinitrateAdempas (Riociquat)NoneWhich of the following apply to you?I do not exercise as much as I shouldI do not eat as healthy as I shouldI smoke or use tobaccoI use other nicotine productsI drink more than 2 drinks per dayI do not sleep as much as I shouldI'm 20+ poulds overweightI am frequently under a lot of stressNone applyHave you or are you currently using any of the following recreational drugs?MethanphetaminesPoppers or RushAmyl Nitrate or Butyl NitrateCocaineMollyOtherNo, I have never used any recreational drugsIs there anything else you want your doctor to know?Is there anything else you want your doctor to know? Drop files here or Accepted file types: jpg, gif, png, pdf.