Erectile Dysfunction Questionnaire
Start your consultation
In just a few steps, your order will be ready to go
- Answer a few quick questions
- Pick and confirm your treatment
- Review your order and pay
If your reviewing physician decides that you aren't a good candidate for treatment your order will be cancelled and refunded in full. We will only charge you for products that are shipped to you.
Do you ever have a problem getting or maintaining an erection that is rigid enough for sex?
Call us at 1-877-853-0312
Have you ever been formally treated for ED or tried any medicines, vitamins, or supplements to treat it?
Call us at 1-877-853-0312
Have you had a physical exam with a healthcare provider in the past 5 years?
Call us at 1-877-853-0312
Do any of the following cardiovascular risk factors apply to you? Select all that apply.
Call us at 1-877-853-0312
Do you have or have you previously been diagnosed with any of the following? Check all that apply.
Call us at 1-877-853-0312
Do you use any of the following recreational drugs?
Call us at 1-877-853-0312
Do you have a marked curve or bend in the penis that interferes with sex, or Peyronie's Disease?
Call us at 1-877-853-0312
Do you have now, or have you ever had any of the following conditions? Select all that apply.
Call us at 1-877-853-0312
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
