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Since these are prescription meds, we need to ask a few health questions.
Why we ask: Your answers help the licensed clinician determine if treatment is right for you.
Here's how it works:
- Answer a few quick questions
- Choose your treatment
- Complete your order and checkout
Erectile Dysfunction Questionnaire
Do you ever have a problem getting or maintaining an erection that is rigid enough for sex?
Call us at 1-877-853-0312
Erectile Dysfunction Questionnaire
Have you ever been formally treated for ED or tried any medicines, vitamins, or supplements to treat it?
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Erectile Dysfunction Questionnaire
How long ago was your last use of this medication?
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Erectile Dysfunction Questionnaire
Did you experience any side effects from your treatments for ED?
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Erectile Dysfunction Questionnaire
Have you had a physical exam with a healthcare provider in the past 5 years?
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Erectile Dysfunction Questionnaire
Was your blood pressure taken in the past year?
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Erectile Dysfunction Questionnaire
Do you take any of the following medicines? Select all that apply
Call us at 1-877-853-0312
Erectile Dysfunction Questionnaire
Do any of the following cardiovascular risk factors apply to you? Select all that apply.
Call us at 1-877-853-0312
Erectile Dysfunction Questionnaire
Do you have or have you previously been diagnosed with any of the following? Check all that apply.
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Erectile Dysfunction Questionnaire
Do you experience any of the following cardiovascular symptoms?
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Erectile Dysfunction Questionnaire
Do you use any of the following recreational drugs?
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Erectile Dysfunction Questionnaire
Do you have a marked curve or bend in the penis that interferes with sex, or Peyronie's Disease?
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Erectile Dysfunction Questionnaire
Do you experience pain with erections or with ejaculation?
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Erectile Dysfunction Questionnaire
Do you have a foreskin that is too tight?
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Erectile Dysfunction Questionnaire
Have you had active bending of your penis within the last 12 months?
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Erectile Dysfunction Questionnaire
Do you have now, or have you ever had any of the following conditions? Select all that apply.
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Erectile Dysfunction Questionnaire
Have you had a heart attack in the last three months?
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Erectile Dysfunction Questionnaire
What other information or questions do you have for the doctor?
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Erectile Dysfunction Questionnaire
Consent (PDE5i) - Please read the following about all PDE5i
You have been diagnosed with or have reported that you have a known diagnosis of organic or psychogenic (situation) erectile dysfunction, a condition characterized by the inability to achieve or maintain an erection sufficient for satisfactory sexual performance. Phosphodiesterase Type 5 Inhibitors (PDE5i) are medications prescribed to treat this condition by enhancing erectile function.
Common PDE5 inhibitors include Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra), and Avanafil (Stendra). These medications work by increasing blood flow to the penis during sexual stimulation.
The use of PDE5 inhibitors may improve your ability to achieve and maintain an erection, enhance sexual performance and satisfaction, and improve your quality of life and personal relationships.
While PDE5 inhibitors are generally well-tolerated, possible side effects may include headache, flushing, indigestion or upset stomach, nasal congestion, dizziness or lightheadedness, visual disturbances such as blurred vision or changes in color perception, back pain or muscle aches (more common with Tadalafil), hearing loss or ringing in the ears (rare), priapism (a prolonged erection lasting more than four hours), and allergic reactions like rash, itching, or swelling. Do not use PDE5 inhibitors if you take nitrates for chest pain (angina), use recreational drugs called "poppers" (amyl nitrate or nitrite), have severe heart or liver problems, have recently had a stroke or heart attack, or have low blood pressure.
Alternative treatments include lifestyle changes such as exercise, weight loss, quitting smoking, and reducing alcohol intake; psychotherapy or counseling for psychological causes of erectile dysfunction; vacuum erection devices, which are mechanical pumps to induce erections; penile injections or suppositories where medications are administered directly to the penis; hormone therapy if low testosterone levels are contributing to erectile dysfunction; and surgical options like penile implants or vascular surgery.
I understand the potential benefits, risks, and side effects of using PDE5 inhibitors. I have been
informed about alternative treatment options. I agree to inform my healthcare provider of any
side effects or adverse reactions I may experience. I understand that this consent is voluntary
and that I can withdraw from treatment at any time.
By selecting below, I consent to the use of PDE5 inhibitors for the treatment of my erectile
dysfunction.
Call us at 1-877-853-0312
Acknowledgement
Pharmacy Consent
