Are you currently seeking treatment to help obtain or maintain an erection?
Yes
or
No
Next
How long have you been having difficulty getting or maintaining an erection?
0-6 months
6-12 months
More than 1 year
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How concerned are you about this problem?
Not at all
Somewhat
Very
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Which medications/devices for erectile dysfunction in the past?
Viagra
Cialis
Levitra
Device
Other
None
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Did your medication or device help?
Did not work
Helped somewhat
Wasn’t helpful
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Does any of the following apply to you?
Not healthy enough to have sex
Chest pain/shortness of breathe while exercising the past year
I have experienced unexplained blurry vision or headaches
Unable to walk 1 mile on a flat surface
Diagnosed with low blood pressure
None apply to me
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Do you have any of the following conditions?
Retinitis Pigmentosa or anterior ischemic optic neuropathy
Severe aortic stenosis or Hypertrophic obstructive cardiomyopathy
Pulmonary Hypertension
Sickle cell anemia, myeloma, or leukemia
Multiple sclerosis (MS) or similar disease, spinal injuries or paralysis
None apply to me
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Within the past 6 months, have you had a heart attack or cardiac surgery?
Yes
or
No
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Do you have any of the following?
Select that apply
History of kidney failure/kidney disease
Have seen a kidney specialist (Nephrologist)
Severe Kidney Disease
Previously/Currently on dialysis
None of the above
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Have you ever had any physical abnormalities with your genitals?
Previous priapism
Peyronie's disease
Painful erection due to bend of penis
Genital surgery
None apply to me
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History of kidney failure/kidney disease
Do you have any lab tests within the past 6 months that include your Creatinine, CrCl, or GFR that you are able to share?
Select that apply
Yes
or
No
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Have you done any of the following recreational drugs in the past 3 months?
Disclaimer: death can result if ED meds are used in conjunction with recreational drugs.
Poppers or Rush
Cocaine
Methamphetamine
None apply to me
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Do you take any of the following medications?
Disclaimer: death can result if ED meds are used in conjunction with Nitrates
Adempas
Alpha blockers
Cimetidine, Erythromycin, or Digitoxin
Ketoconazole/Itraconazole(oral only)
Ritonavir/Saquinavir
Trazodone
None apply to me
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Have you ever been prescribed nitrates/nitroglycerin?
Yes
or
No
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Have you had your vitals tested by a medical practitioner in the past 3 years?
This includes weight, blood pressure, and heart rate
Yes
or
No
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What is your blood pressure on an average day?
Normal
110-120mmHG
70-80mmHG
Mildly elevated
121-130mmHG
80-90mmHG
Elevated
141-160mmHG
90-100mmHG
Severly elevation
>160mmHG
110mmHG
Mildly low
100-110mmHG
65-70mmHG
Very low
<95mmHG
<65mmHG
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Do you have any more questions or anything else you would like your doctor to know?
This includes weight, blood pressure, and heart rate
Yes
or
No
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Next
Progress
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