Questionarre 2

* 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? *

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? *

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.? *

BEGAN SUDDENLY AND HAS CONTINUED BEGAN GRADUALLY AND GOT WORSE OVER TIME

DO YOU GET ERECTIONS WHEN MASTURBATING? *

YES SOMETIMES RARELY NO

DO YOU GET ERECTIONS WHEN ASLEEP OR FIRST THING IN THE MORNING? *

YES SOMETIMES RARELY NO

DID YOUR E.D. BEGIN WITH A NEW SEXUAL PARTNER? *

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: *

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: *

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)? *

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? *

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? *

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: *

Please enter your DIASTOLIC number: *

E.D. CAN BE RELATED TO TOBACCO, ALCOHOL, OR DRUG USE. SELECT ALL THAT APPLY TO YOU: *

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: *

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: *

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? *

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 WORRYING TOO MUCH ABOUT DIFFERENT THINGS? *

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: *

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: *

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

ARE YOU ALLERGIC TO ANY MEDICINES? *

YES NO

PLEASE LIST ALL MEDICATIONS THAT YOU ARE ALLERGIC TO: *

DID YOU HAVE ANY SIDE EFFECTS FROM YOUR PREVIOUS ED MEDICINES THAT WOULD STOP YOU FROM USING THEM AGAIN? *

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? *

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: *

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? *

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: *

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? *

NO YES, PLEASE MAIL MY MEDICAL RECORD TO MY DOCTOR

PHYSICIAN ADDRESS: *

FINALLY, IS THERE ANYTHING ELSE WE SHOULD KNOW? *

PHARMACY CONSENT *

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 &
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