Customer Register – Erectile Dysfunction

ERECTILE DYSFUNCTION QUESTIONS

PRE-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)

State

4. What is your date of birth?(Required)

MM slash DD slash YYYY

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ERECTILE DYSFUNCTION QUESTIONS

GENERAL:

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

8. Have you ever been treated with medication for ED?(Required)

Yes

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

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

15. Please list what you are allergic to(Required)

16. Have you had any surgeries or hospitalizations?(Required)

Yes

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 apply

21. Are there any other medical conditions you haven’t shared with us already?(Required)

Yes

Be sure to include any medical conditions that you treat with medications

22. In the last 3 months have you experienced any of the following?(Required)

Yes

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 apply

24. 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)

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Email(Required)

Password(Required)

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ERECTILE DYSFUNCTION QUESTIONS

PRE-QUESTIONS:

ERECTILE DYSFUNCTION QUESTIONS

GENERAL:

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