Manelyhood

Have you ever been formally treated for ED or tried any medicines, vitamins, or supplements to treat it?

Yes

No

Do you experience pain with erections or with ejaculation?

Yes

No

What is your height in feet and inches?

What is your weight in pounds?

Have you had a physical exam with a healthcare provider in the past 5 years?

Yes, I am in good health

Yes, but they found problems

No

Please explain any issues during your last physical exam if you had any

Was your blood pressure taken in the past year?

Yes

No, I will get a new blood pressure measurement

What was the value?

Do you have now, or have you ever had any of the following conditions? Select all that apply.

None apply

Priapism (erection lasting longer than 4 hours)

Retinitis Pigmentosa

Sudden vision loss

Neurologic disease or stroke

Blood clotting disorder, abnormal bleeding or bruising

Stomach or intestinal ulcer

A prior heart attack or heart failure

Peripheral artery disease

Any history of QT prolongation

Sickle cell anemia, myeloma, leukemia

Idiopathic hypertrophic subaortic stenosis

Use of blood thinners

Have you had a stroke within the last six months?

Yes

No

Have you had a heart attack within the last three months?

Yes

No

Do you experience any of the following cardiovascular symptoms?

None of these apply to me

Chest pain or shortness of breath when climbing 2 flights of stairs or walking 4 blocks

Chest pain or shortness of breath with sexual activity

Unexplained fainting or dizziness

Prolonged cramping of the legs with exercise

Abnormal heart beats or rhythms

Chest pain or shortness of breath when climbing 2 flights of stairs or walking 5 blocks

Do any of the following cardiovascular risk factors apply to you? Select all that apply.

None apply

Diabetes

High cholesterol

High blood pressure

My father had a heart attack or heart disease at 55 years or younger

My mother had a heart attack or heart disease at 65 years or younger

My mother had a heart attack or heart disease at 66 years or older

Do you take any of the following medicines? Select all that apply.

None apply

Nitroglycerin spray, ointment, patches or tablets

Isosorbide mononitrate, or Isosorbide dinitrate (Isordil, Dilatrate, Sorbitrate, Imdur, Ismo, Monoket)

Other medicines containing nitrates

Alpha blocker medications: doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin)

Riociguat (Adempas)

Please list all your current medications including dosages

Do you have or have you previously been diagnosed with any of the following? Check all that apply.

None apply

Prostate cancer

Enlarge prostate

Kidney transplant or any condition affecting the kidney

Pulmonary artery hypertension PAH

Liver disease

Multiple Sclerosis or similar disease

Spinal injuries and/or paralysis

Neurological disease

Stomach, testinal, or bowel ulcers

Heart arrhythmias

Any acquired, congenital, or developmental abnormalities of the heart including heart murmurs

Please identify all your current medical conditions

Please list all of your known allergies

Do you use any of the following recreational drugs?

No I don't use any of these

Poppers or Rush

Amyl nitrate or butyl nitrate

Cocaine

Cigarettes

Other

What other information or questions do you have for the doctor?

Final Step

What is your name?What is your date of birth?What is your phone number?What is your email address?