ERECTILE DYSFUNCTION QUESTIONSPRE-QUESTIONS:1. How often do you have trouble getting or keeping an erection during sex?(Required) Every time Half the time On Occasion Rarely 2. What results are you looking for?(Required) Getting and maintaining an erection during sex Increasing my libido All of the above 3. Select your state(Required) AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State 4. What is your date of birth?(Required) MM slash DD slash YYYY ContinueERECTILE DYSFUNCTION QUESTIONSGENERAL:1. How often do you have trouble getting or keeping an erection during sex?(Required) Always More than half the time Sometimes Rarely Never 2. How often do you have trouble getting or keeping an erection during sex?(Required) Difficulty achieving erections Difficulty maintaining erections Both 3. How did your ED start?(Required) Suddenly Gradually worsened over time 4. Rate the typical hardness of your erection during masturbation(Required) Penis does not enlarge Penis is larger, but not hard Penis is hard, but not hard enough for penetration Penis is hard enough for penetration, but not completely hard Penis is completely hard and fully rigid 5. Rate the typical hardness of your spontaneous erections in the middle of the night or the morning(Required) Penis does not enlarge Penis is larger, but not hard Penis is hard, but not hard enough for penetration Penis is hard enough for penetration, but not completely hard Penis is completely hard and fully rigid 6. Rate the typical hardness of your erection with a sexual partner.(Required) Penis does not enlarge Penis is larger, but not hard Penis is hard, but not hard enough for penetration Penis is hard enough for penetration, but not completely hard Penis is completely hard and fully rigid 7. Do you have low sex drive, an overall lack of energy, or a descrease in physical strength or endurance?(Required) Yes No 8. Have you ever been treated with medication for ED?(Required) Yes No 9. Which of the following treatments have you used to treat your ED in the past?(Required) Sildenafil (Viagra or generic) Tadalafil (Cialis or generic) Vardenafil (Levitra or generic) Avanafil (Stendra) Other 10. Were you happy with your treatment with *answer of question 8*(Required) Yes No 11. Please tell us about your experience with *answer of question 8*(Required)12. What is your gender?(Required) Man Woman Transgender man Transgender woman Genderqueer/non-binary Agender Questioning Different identity We ask this question of all of our patients to ensure that we provide you with safe and effective care. We are inclusive of all people.13. What was your sex assigned at birth?(Required) Male Female 14. Do you have any allergies or medication reactions?(Required) Yes No 15. Please list what you are allergic to(Required)16. Have you had any surgeries or hospitalizations?(Required) Yes No 17. Please tell us the dates and reasons for your surgeries or hospitalizations.(Required)18. Do you experience any of the following cardiovascular symptoms?(Required) Chest pain when climbing 3 flights of stairs or walking 4 blocks Chest pain with sexual activity Unexplained fainting or dizziness Abnormal heart beats or rhythms None of these apply to me 19. Do you have or have you previously been diagnosed with any of the following?(Required) Stroke, mini stroke, or TIA Diabeties Mental health or psychiatric conditions Prostate conditions Kidney diseases or conditions Liver, stomach, or other gastrointestinal conditions Nerve, spinal cord, or brain disorders Heart conditions or diseases Vascular conditions affecting arteries or veins Penis conditions other than ED Low blood pressure High blood pressure HIV / AIDS Other chronic medical conditions None of these apply to me 20. Do you have or have you previously been diagnosed with any of the following heart conditions?(Required) Congestive heart failure Coronary artery disease (without prior heart attack) Coronary bypass surgery Coronary angioplasty/stent Heart attack Idiopathic hypertrophic subaortic stenos (aka hypertrophic obstructive cardiomyopathy) Long QT syndrome (QT Prolongation) Other electrical heart abnormalities None of these apply to me Check all that apply21. Are there any other medical conditions you haven’t shared with us already?(Required) Yes No Be sure to include any medical conditions that you treat with medications22. In the last 3 months have you experienced any of the following?(Required) Yes No Fainting, almost fainting, severe headaches, blurry or double vision, recurrent nosebleeds.23. Have you smoked, ingested, or used any of the following within the past 3 months?(Required) Poppers or Rush (Amyl Nitrate or Butyl Nitrate) Cocaine Methamphetamine (Crystal Meth) Ecstasy, Molly, or MDMA Cigarettes Cannabis Other No, I have not used any recreational drugs in the past 3 months Check all that apply24. Here’s your first message to your clinician. Please introduce yourself and ask the clinician any questions you have about the treatment. Feel free to include anything else you want them to know about your condition.(Required)ContinueName(Required) First Last Email(Required) Password(Required) Enter Password Confirm Password
