First Name *

Last Name *

Date of birth *

Gender *

Address *

City *

State *

Postal code *

Phone *

Email *

If You Have A Code, Enter It Here.

Do You Have A Doctor? *

If Yes, Please Enter Your Doctor Name

If Yes, Please Enter Your Doctor Phone Number

Do You Agree With The Telehealth Consent? *

Have you had a physical exam in the last three years? *

If yes, were there any abnormalities with the exam?

Are you able to have sex like you did when you were in your 20's? *

With sexual stimulation can you…. *

Are you able to maintain an erection during intercourse? *

With your erection, are you... *

Have you taken any of the following as treatment for erectile dysfunction? (select all that apply) *

Have you ever been prescribed nitrates/nitroglycerin? *

In the past several months, have you had any of the following? *

Chest Pain

Passing Out

Dizziness/Seizures

None Of The Above

Is there a family history of any of the following? (check all that apply) *

Cardiovascular Disease

Unexplained Death

None Of The Above

Do you exercise regularly? *

If yes, how often do you exercise?

Have you had elevated Blood pressure in the past 6 months? *

Please Enter Blood Pressure *

Do you have any allergies? *

If yes, please list allergies.

Are you currently taking any medications? *

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

Please Fill Out Medical Intake Form

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