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How do you rate your confidence that you could get and keep an erection?(Required)
When you have erections with sexual stimulation, how often are your erections hard enough for penetration?(Required)
How often were you able to maintain your erection for a long enough period to satisfy yourself and your partner?(Required)
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?(Required)
When you attempted sexual intercourse, how often was it satisfactory to you?(Required)
How did your ED begin?(Required)
How satisfied have you been with your overall sex life?(Required)
Have you tried ED medication before?(Required)
Have you ever been diagnosed with or treated for high or low blood pressure?(Required)
Have you ever been diagnosed with any of these heart conditions?(Required)
Do you experience any of these symptoms? (Please check off all that apply)(Required)
Have you ever been diagnosed with or experienced the following?(Required)
Have you used any of these recreational drugs in the last 6 months?(Required)
Do you currently use or have prescriptions for any of these medications?(Required)
Is there anything else you'd like your provider to know?(Required)
ED can be a sign of other undiagnosed medical issues, like heart problems. Smoking, marijuana use, obesity, depression, and low testosterone can all play a role in erectile function (and dysfunction). In addition to seeking ED treatment, we recommend you speak with your primary care provider to rule out other underlying conditions.
Let's talk about treatment preferences. If you have any preferences, we want to take those into account. Your provider will still review everything and make sure you're getting the best treatment for you.
Which treatment option best fits your needs?
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Please attest to the following confirming that all information you have provided to us is true and complete. If you do not agree, you may not submit this form. Consent: I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care.(Required)
What is your preferred language for communication with our medical team? (¿Cuál es su idioma preferido para comunicarse con nuestro equipo médico?)(Required)
Address(Required)
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