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PATIENT QUESTIONNAIRE
What is Erectile Dysfunction
FAQ
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HIPPA PRIVACY POLICY
INFORMED CONSENT FOR TELEMEDICINE SERVICES
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PATIENT QUESTIONNAIRE
What is Erectile Dysfunction
FAQ
About
HIPPA PRIVACY POLICY
INFORMED CONSENT FOR TELEMEDICINE SERVICES
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Contact
Product
Phone:
615-307-0050
*
Indicates required field
DO YOU EVER HAVE A PROBLEM GETTING OR MAINTAINING AN ERECTION THAT IS SATISFYING ENOUGH FOR SEX? IF YOU DO NOT HAVE A PROBLEM WITH AN ERECTION, YOU SHOULD NOT USE OUR SERVICE. WHICH OF THE FOLLOWING APPLY TO YOU?
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YES, EVERY TIME I WANT AN ERECTION
YES, SOMETIMES WHEN I WANT AN ERECTION
YES, RARELY WHEN I WANT AN ERECTION
NO, NEVER HAVE PROBLEMS WITH AN ERECTION
PREMATURE EJACULATION, COMING EITHER BEFORE OR SHORTLY AFTER SEX (PENETRATION) STARTS, CAN OCCUR IN SOME MEN. IF THIS IS THE ONLY PROBLEM YOU HAVE WITH SEX, THEN YOU SHOULD SEE A DOCTOR IN PERSON AND NOT USE OUR SERVICE. WHICH OF THE FOLLOWING APPLY TO YOU?
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ONLY HAVE PROBLEMS WITH PREMATURE EJACULATION. NEVER HAVE PROBLEMS WITH AN ERECTION.
HAVE PROBLEMS WITH BOTH PREMATURE EJACTULATION AND ERECTION
NONE APPLY. DO NOT HAVE PREMATURE EJACULATION
HOW DID YOUR E.D. BEGIN? SELECT THE ONE THAT BEST DESCRIBES YOUR E.D.?
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BEGAN SUDDENLY AND HAS CONTINUED
BEGAN GRADUALLY AND GOT WORSE OVER TIME
DO YOU GET ERECTIONS WHEN MASTURBATING?
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YES
SOMETIMES
RARELY
NO
DO YOU GET ERECTIONS WHEN ASLEEP OR FIRST THING IN THE MORNING?
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YES
SOMETIMES
RARELY
NO
DID YOUR E.D. BEGIN WITH A NEW SEXUAL PARTNER?
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YES
NO
HAVE YOU HAD A PHYSICAL EXAM BY A DOCTOR IN THE PAST 5 YEARS? IF YOU HAVE NOT, THEN WE RECOMMEND YOU SEE A DOCTOR BEFORE USING OUR SERVICE. SELECT ONE OF THE FOLLOWING:
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YES
NO
Choose OneDID YOUR PHYSICAL EXAM INCLUDE AN EXAM OF THE GENITALS (INCLUDING THE TESTICLES, PENIS)? IF YOU HAVE NOT, WE RECOMMEND YOU SEE A DOCTOR BEFORE USING OUR SERVICE. SELECT ONE OF THE FOLLOWING:
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YES, IT WAS NORMAL
NO
I DID NOT HAVE A PHYSICAL EXAM BY A DOCTOR IN THE PAST 5 YRS
THE MEDICINES WE PRESCRIBE ARE ONLY APPROPRIATE FOR CERTAIN PATIENTS. WHICH OF THE FOLLOWING BEST DESCRIBES YOUR SEX DRIVE OR DESIRE TO HAVE SEX (LIBIDO)?
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I STILL THINK ABOUT SEX AND WANT TO HAVE SEX. MY SEX DRIVE OR DESIRE TO HAVE SEX IS NORMAL
I DO NOT THINK ABOUT SEX OR DO NOT WANT TO HAVE SEX BECAUSE I HAVE PROBLEMS WITH HAVE AN ERECTION
I DO NOT THINK ABOUT SEX OR DO NOT WANT TO HAVE SEX. MY SEX DRIVE OR DESIRE TO HAVE SEX IS ABNORMAL
OTHER
OVER THE PAST TWO WEEKS, HOW OFTEN HAVE YOU BEEN BOTHERED BY LITTLE INTEREST OR PLEASURE IN DOING THINGS?
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NOT AT ALL
SEVERAL DAYS
MORE THAN HALF OF THE DAYS
NEARLY EVERY DAY
OVER THE PAST TWO WEEKS, HOW OFTEN HAVE YOU BEEN BOTHERED BY FEELING DOWN, DEPRESSED, OR HOPELESS?
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NOT AT ALL
SEVERAL DAYS
MORE THAN HALF OF THE DAYS
NEARLY EVERY DAY
ENTER YOUR BLOOD PRESSURE READING TAKEN WITHIN THE LAST SIX MONTHS. FOR EXAMPLE SYSTOLIC 120/ DIASTOLIC 80:
HIGH = SYSTOLIC 140 OR ABOVE OR DIASTOLIC 90 OR ABOVE
PRE-HIGH = SYSTOLIC BETWEEN 121-139 OR DIASTOLIC BETWEEN 81-89
NORMAL = SYSTOLIC 120 OR LESS AND DIASTOLIC 80 OR LESS
Please enter your SYSTOLIC number:
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Please enter your DIASTOLIC number:
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E.D. CAN BE RELATED TO TOBACCO, ALCOHOL, OR DRUG USE. SELECT ALL THAT APPLY TO YOU:
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SMOKE CIGARETTES OR USE OTHER TOBACCO PRODUCTS
DRINK MORE THAN TWO ALCOHOLIC BEVERAGES PER DAY
USE A RECREATIONAL DRUG CALLED AMYL NITRATE OR BUTYL NITRATE (POOPERS, RUSH)
USE OTHER RECREATIONAL DRUGS
NONE APPLY
SOME CASES OF E.D. ARE TOO COMPLEX FOR US TO MANAGE EFFECTIVELY ONLINE. INSTEAD, YOU SHOULD SEE A DOCTOR IN PERSON AND NOT USE OUR SERVICE. DO YOU HAVE ANY OF THESE CONDITIONS? SELECT ALL THAT APPLY TO YOU:
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ANY CONDITION WHERE SEX IS NOT ADVISED
KIDNEY PROBLEMS INCLUDING HAVING HAD A KIDNEY TRANSPLANT
LIVER PROBLEMS
NEUROLOGIAL PROBLEMS LIKE MULTIPLE SCLEROSIS OR MOTOR NEURON DISEASE
SPINAL INJURY OR PARALYSIS
HIV
PREVIOUS SURGERY ON YOUR PROSTATE OR PELVIS
RADIATION THERAPY TO YOUR PELVIS
NONE APPLY
SOME GENITAL ISSUES CAN CAUSE DIFFICULTY WITH SEX AND YOU SHOULD SEE A DOCTOR IN PERSON AND NOT USE OUR SERVICE. DO YOU HAVE ANY OF THESE CONDITIONS? SELECT ALL THAT APPLY TO YOU:
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PHYSICAL ABNORMALITIES OF THE PENIS, CURVING OR BENDING OF THE PENIS
SCARRING OF THE PENIS. FEELS LIKE LUMPS OR HARD TISSUE UNDER THE SKIN
PAIN WITH ERECTIONS
TIGHT FORESKIN
NONE APPLY
OVER THE PAST TWO WEEKS, HOW OFTEN HAVE YOU BEEN BOTHERED BY FEELING NERVOUS, ANXIOUS, OR ON EDGE?
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NOT AT ALL
SEVERAL DAYS
MORE THAN HALF OF THE DAYS
NEARLY EVERY DAY
IT CAN BE LIFE-THREATENING TO TAKE ED MEDICINE IF YOU NOW HAVE OR HAVE EVER HAD ANY OF THE FOLLOWING HEART, BLOOD PRESSURE, OR CARDIOVASCULAR PROBLEMS. INSTEAD, YOU SHOULD SEE A DOCTOR IN PERSON AND NOT USE OUR SERVICE. SELECT ALL THAT APPLY TO YOU:
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DIABETES
HIGH BLOOD PRESSURE
LOW BLOOD PRESSURE
ANGINA
STROKE
HEART ATTACK
HEART FAILURE
HISTORY OR FAMILY HISTORY OF QT PROLOGATION
HEART ARRYTHMIA
HEART VALVE PROBLEMS
HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY (HCM)
PERIPHERAL VASCULAR DISEASE OR CLAUDICATION
NONE APPY
OVER THE PAST TWO WEEKS, HOW OFTEN HAVE YOU BEEN BOTHERED BY WORRYING TOO MUCH ABOUT DIFFERENT THINGS?
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NOT AT ALL
SEVERAL DAYS
MORE THAN HALF OF THE DAYS
NEARLY EVERY DAY
E.D. CAN BE THE FIRST SIGN OF HEART DISEASE. DEPENDING ON YOUR RISK FACTORS, YOU MAY NEED TO SEE A DOCTOR IN PERSON AND NOT USE OUR SERVICE. WHICH OF THE FOLLOWING ADDITIONAL RISK FACTORS DO YOU HAVE FOR HEART DISEASE? SELECT ALL THAT APPLY TO YOU:
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HIGH CHOLESTEROL
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
NONE APPLY
IT CAN BE LIFE-THEATENING TO TAKE ED MEDICATION IF YOU NOW HAVE OR HAVE EVER HAD ANY OF THE FOLLOWING MEDICAL CONDITIONS. INSTEAD YOU SHOULD SEE A DOCTOR IN PERSON AND NOT USE OUR SERVICE. SELECT ALL THAT APPLY TO YOU:
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PRIAPRISM ( ERECTION LASTING LONGER THAN FOUR HOURS)
RETINITIS PIGMENTOSA
ANTERIOR ISCHEMIC OPTIC NEUROPATHY (AION)
SICKLE CELL DISEASE
BLOOD CLOTTING DISORDER, ABNORMAL BLEEDING OR BRUISING, OR COAGULOPATHY
MYELOMA OR LEUKEMIA
STOMACH OR INTESTINAL ULCER
NONE APPLY
IT CAN BE LIFE-THEATENING TO TAKE ED MEDICINES IF YOU NOW HAVE OR HAVE EVER HAD ANY OF THE FOLLOWING MEDICAL CONDITIONS. INSTEAD YOU SHOULD SEE A DOCTOR IN PERSON AND NOT USE OUR SERVICE. SELECT ALL THAT APPLY TO YOU:
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NITROGLYCERIN SPRAY, OINTMENT, PATCHES OR TABLETS (NITRO-DUR, NITROLINGUAL, NITROSTAT
NITROMIST, NITROLINGUAL, NITRO-BID, TRANSDERM-NITRO, NITRO-TIME, DEPONIT
MINITRAN, NITREK, NITRODISC, NITROGARD, NITROGLYN, NITROL OINTMENT, NITRONG, NITRO-PAR
ISOSORBIDE MONONITRATE OR ISISORBIDE DINATRATE (ISORDIL, DILATRATE, SORBITRATE, IMDUR, ISMO, MONOKET)
OTHER MEDICINES CONTAINING NITRATES
ALPHA BLOCKERS TO TREAT HIGH BLOOD PRESSURE OR PROSTATE PROBLEMS, INCLUDING DOXAZOSIN (CARDURA)
PRAZOSIN (MINIPRESS), ALFUZOSIN (UROZATRAL), SILODOSIN (RAPAFLO)
TAMSOLOSIN (FLOMAX), TERAZOSIN (HYTRIN)
SILDENAFIL (REVATIO) USED TO TREAT PULMONARY HYPERTENSION
RIOCIGUAT (ADEMPAS) USED TO TREAT PULMONARY HYPERTENSION
NONE APPLY
ARE YOU ALLERGIC TO ANY MEDICINES?
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YES
NO
PLEASE LIST ALL MEDICATIONS THAT YOU ARE ALLERGIC TO:
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WHICH OF THE FOLLOWING PRESRIPTION ED MEDICINES HAVE YOU TAKEN IN THE PAST, REGARDLESS OF WHETHER THEY WORKED WELL? SELECT ALL THAT APPLY TO YOU:
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I NEVER TOOK ANY PRESCRIPTION ED MEDICINES
AVANAFIL (STENDRA) 50MG
ANANAFIL (STENDRA) 200 MG
SILDENAFIL (VIAGRA, REVATIO) 25 MG
SILDENAFIL (VIAGRA, REVATIO) 50 MG
SILDENAFIL (VIAGRA, REVATIO) 100 MG
TALADALIFIL (CIALIS, ADCIRCA) 2.5 MG
TALADALIFIL (CIALIS, ADCIRCA) 5 MG
TALADALIFIL (CIALIS, ADCIRCA) 10 MG
TALADALIFIL (CIALIS, ADCIRCA) 20 MG
VARDENAFIL (LEVITRA) 2.5 MG
VARDENAFIL (LEVITRA) 5 MG
VARDENAFIL (LEVITRA) 10 MG
VARDENAFIL (LEVITRA) 20 MG
NONE APPLY
DID YOU HAVE ANY SIDE EFFECTS FROM YOUR PREVIOUS ED MEDICINES THAT WOULD STOP YOU FROM USING THEM AGAIN?
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NO, NEVER TAKEN ED MEDICINES BEFORE
NO, NEVER HAD SIDE EFFECTS THAT BOTHERED ME
YES
OTHER THAN PRESCRIPTION MEDICINES, HAVE YOU USED OTHER TREATMENTS FOR ED IN THE PAST?INCLUDE PENILE IMPLANTS, PENILE INJECTIONS, PUMPS, SUPPLEMENTS, HERBS, OR OTHER OVER-THE-COUNTER PRODUCTS?
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NO, NEVER USED OTHER TREATMENTS
YES
ARE YOU CURRENTLY TAKING ANY OTHER PRESCRIPTION MEDICINES FOR OTHER MEDICAL ISSUES? ALSO, INCLUDE VITAMINS, HERBS, LIKE PAIN RELIEVERS AND SLEEP AIDS:
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NO
YES
ED CAN BE THE FIRST SIGN OF HARDENING OF THE ARTERIES AND HEART DISEASE. WE RECOMMEND LAB TESTS TO DETERMINE YOUR RISK. LABS ARE ESPECIALLY IMPORTANT IF THIS IS YOUR FIRST ED DIAGNOSIS. DO YOU WANT US TO ORDER BLOOD TESTS TO CHECK FOR UNDERLYING CAUSES?
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YES
NO
IF YES, THEN YOU WILL GO TO A QUEST DIAGNOSTICS CENTER TO HAVE YOUR BLOOD DRAWN. WE’LL ORDER BLOOD TESTS THAT CHECK FOR DIABETES, HIGH CHOLESTEROL, THYROID DISEASE, AND OTHER CONDITIONS THAT MAY CAUSE ED, AND DETERMING YOUR RISK OF HEART DISEASE. WE’LL NOTIFY YOU OF THE RESULTS AND WHAT ACTIONS TO TAKE IF ANY:
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YES
NO
YOU CAN ALWAYS ACCESS YOUR MEDICAL RECORD FROM YOUR ACCOUNT SCREEN. WOULD YOU LIKE US TO ALSO MAIL A COPY TO YOUR DOCTOR?
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NO
YES, PLEASE MAIL MY MEDICAL RECORD TO MY DOCTOR
PHYSICIAN ADDRESS:
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FINALLY, IS THERE ANYTHING ELSE WE SHOULD KNOW?
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PHARMACY CONSENT
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YES, I UNDERSTAND MY PRESCRIPTION MEDICATION WILL BE SHIPPED RIGHT TO MY DOOR
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PLEASE REVIEW OUR LEGAL NOTICE OF HIPPA PRIVACY PRACTICES, AVAILABLE: WWW.MAXIMUS-ED.COM/HIPPA-COMPLIANCE &
WWW.MAXIMUS-ED.COM/INFORMED CONSENT FOR TELEMEDICINE SERVICES
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I acknowledge that I have viewed and consent to the MAXIMUS-ED website privacy policy and consent to the use of telemedicine. *
By signing, I am consenting to being treated by a licensed physician in my state. I certify that all information provided is true to the best of my knowledge. PLEASE TYPE YOUR NAME FOR ACKNOWLEDGEMENT
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Date:
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PATIENT QUESTIONNAIRE
What is Erectile Dysfunction
FAQ
About
HIPPA PRIVACY POLICY
INFORMED CONSENT FOR TELEMEDICINE SERVICES
BLOG
Contact
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