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)

Almost never or never

A few times (less than half the time)

Sometimes (about half the time)

Most times (more than half the time)

Almost always or always

How often were you able to maintain your erection for a long enough period to satisfy yourself and your partner?(Required)

Almost never or never

A few times (less than half the time)

Sometimes (about half the time)

Most times (more than half the time)

Almost always or always

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?(Required)

Extremely difficult

Very difficult

Difficult

Slightly difficult

Not difficult

When you attempted sexual intercourse, how often was it satisfactory to you?(Required)

Almost never or never

A few times (less than half the time)

Sometimes (about half the time)

Most times (more than half the time)

Almost always or always

How did your ED begin?(Required)

Gradually, but has worsened over time

Suddenly, but not with a new partner

Suddenly, with a new partner

I don't know how it began

How satisfied have you been with your overall sex life?(Required)

Have you tried ED medication before?(Required)

Yes

No

If yes, please list medication(s) previously tried:(Required)

Have you ever been diagnosed with or treated for high or low blood pressure?(Required)

No

Yes, for high blood pressure

Yes, for low blood pressure

I'm not sure

Have you ever been diagnosed with any of these heart conditions?(Required)

Arrhythmia

Coronary artery disease (narrowing of the heart vessels)

Coronary bypass surgery, Heart attack

Idiopathic Hypertrophic Subaortic Stenosis (aka hypertrophic obstructive cardiomyopathy)

Long QT Syndrome

Any congenital or developmental heart problems

Pulmonary HTN (a rare condition that refers to the blood vessels to the lungs and isn't the same as high blood pressure)

Heart failure

None of these

Do you experience any of these symptoms? (Please check off all that apply)(Required)

Chest pain when climbing stairs or walking

Chest pain during sexual activity

Sudden loss of vision due to loss of blood flow to your eye (aka anterior ischemic optic neuropathy)

Unexplained fainting or dizziness

Cramping or pain in the calves or legs with exercise (aka claudication)

None of these

Have you used any of these recreational drugs in the last 6 months?(Required)

Crystal meth (methamphetamines or amphetamines)

Poppers or Rush

Amyl Nitrate or Butyl Nitrate

Cocaine

Molly (MDMA, ecstasy)

No, I haven't used these recreational drugs in the last 6 months

Please list all current medical conditions. Please type N/A if none.(Required)

Do you currently use or have prescriptions for any of these medications?(Required)

Any medication containing nitrates

Any ALPHA blocker, NOT beta blocker (like Flomax, Cardura, and Minipress)

Nitroglycerin in any form (spray, tablet, patch, or ointment)

Supplements that boost nitric oxide (like L-arginine, L-citrulline, beet root powder/extract/juice concentrate)

Monoket (isosorbide mononitrate), Bidil, or Isordil (isorbide dinitrate), which are commonly prescribed to prevent chest pain caused by heart disease)

Antiretrovirals or any treatment for HIV

Adempas (riociguat)

None of the above

Please list all prescription or over-the-counter medications and supplements you are currently taking. Please type N/A if none(Required)

Please list allergies to prescription or over-the-counter medicines, herbs, vitamins, supplements, food, dyes, or anything else. Please type N/A if none(Required)

Is there anything else you'd like your provider to know?(Required)

Yes

No

Please leave your message to your doctor here.(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?

Sildenafil

Tadalafil

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Weight

What is your preferred language for communication with our medical team? (¿Cuál es su idioma preferido para comunicarse con nuestro equipo médico?)(Required)

English / Inglés

Spanish / Español

First Name(Required)

Last Name(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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Stripe Setup ID(Required)

Promo Code

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Product ID

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Product Name

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Product Bundle ID

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