Please Fill Out Medical Intake Form
First Name
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Last Name
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Date of birth
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Gender
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Select Your Gender
Male
Female
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Address
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City
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State
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Postal code
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Phone
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Email
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If You Have A Code, Enter It Here.
Do You Have A Doctor?
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Do You Have A Doctor?
Yes
No
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If Yes, Please Enter Your Doctor Name
If Yes, Please Enter Your Doctor Phone Number
Do You Agree With The Telehealth Consent?
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Do You Agree With The Telehealth Consent?
Yes
No
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Have you had a physical exam in the last three years?
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Have you had a physical exam in the last three years?
Yes
No
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If yes, were there any abnormalities with the exam?
If yes, were there any abnormalities with the exam?
N/A
Yes
No
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Are you able to have sex like you did when you were in your 20's?
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Are you able to have sex like you did when you were in your 20's?
Yes
No
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With sexual stimulation can you….
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With sexual stimulation can you….
Initiate An Erection
Maintain An Erection
Neither Initiate Or Maintain An Erection
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Are you able to maintain an erection during intercourse?
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Are you able to maintain an erection during intercourse?
Yes
No
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With your erection, are you...
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With your erection, are you...
Strongly Dissatisfied
Dissatisfied
Neither Satisfied nor Dissatisfied
Satisfied
Strongly Satisfied
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Have you taken any of the following as treatment for erectile dysfunction? (select all that apply)
*
Sildenafil (Viagra)
Tadalafil (Cialis)
Vardenafil (Levitra)
Testosterone Replacement
Injections
Surgery or Use of Pumps
Have you ever been prescribed nitrates/nitroglycerin?
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Have you ever been prescribed nitrates/nitroglycerin?
Yes
No
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In the past several months, have you had any of the following?
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Chest Pain
Passing Out
Dizziness/Seizures
None Of The Above
Is there a family history of any of the following? (check all that apply)
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Cardiovascular Disease
Unexplained Death
None Of The Above
In the Last Three Months, Have You Used Any of the Following Drugs Recreationally? (check all that apply)
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Cocaine
Poppers or Rush
Opiates/Heroin
Methamphetamine
Molly (MDMA)
Other
None
Do you exercise regularly?
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Do you exercise regularly?
Yes
No
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If yes, how often do you exercise?
If yes, how often do you exercise?
Everyday
At Least 3 Times per Week
Weekly
Less Than Once Per Week
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Have you had elevated Blood pressure in the past 6 months?
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Have you had elevated Blood pressure in the past 6 months?
Yes
No
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Please Enter Blood Pressure
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Do you have any allergies?
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Do you have any allergies?
Yes
No
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If yes, please list allergies.
Are you currently taking any medications?
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Are you currently taking any medications?
Yes
No
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If yes, please list medications.
Which of the following apply to you (if any)?
*
I get less than 2 hours of exercise per week
I do not eat as healthy as I would like
I smoke or use tobacco (e.g., chewing tobacco, snuff)
I use other nicotine containing products (e.g., vaping)
I drink more than 2 alcoholic drinks per day
I get less than 7 hours of sleep per night, on average
I’m 25+ pounds overweight
I am frequently under a lot of stress
None apply to me
Have you experienced any of the following conditions? (check all that apply)
*
Enlarged prostate
Weight gain/management
Sleep/Insomnia
Hair loss
Low Testestorone
Blood sugar/diabetes
Acne/Roscecia/Hyperpigmentation
Joint Issues
Toe Nail Fungus
Pain Management
None
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