Medical Intake Questionnaire

Complete all required fields for clinical review.

Selected plan

Personal Information

First name *

Last name *

Email *

Phone *

Date of birth *

Erectile Function

How long have you experienced erectile dysfunction? *

How often is it present? *

Do you wake with morning erections? *

Can you get an erection during masturbation? *

Has your libido changed? *

Severity from 1–10? *

Does your partner know you are seeking treatment? *

Can you achieve penetration? *

Can you achieve orgasm? *

How long does an erection typically last? *

Heart & General Health

Has a doctor advised avoiding sexual activity due to a heart condition? *

Have you had a heart attack, stroke, or heart surgery? *

Do you experience chest pain during activity or sex? *

Do you have low blood pressure or fainting? *

Medication Safety

Are you currently taking nitrates for chest pain? *

Are you taking alpha-blockers? *

Are you taking medication for pulmonary hypertension? *

Medical History

Kidney disease *

Liver disease *

Peyronie's disease *

Multiple sclerosis *

Parkinson's disease *

Spinal cord injury *

Low testosterone *

Sleep apnea *

Depression or anxiety *

Previous pelvic surgery *

Allergies & Lifestyle

Are you allergic to medications? *

If yes, list allergies *

Smoking status *

Height *

Weight *

Exercise frequency *

Previous Treatment & Goals

Past treatment side effects *

Previous strength *

What would you like to improve? *

Required Safety Questions

Have you had an erection lasting more than four hours? *

Have you been diagnosed with sickle cell disease, leukemia, or multiple myeloma? *

Have you experienced sudden vision or hearing loss? *

I certify that my information is accurate and understand that submission does not guarantee a prescription.

This form does not provide emergency care. Call 911 for a medical emergency.