1 OF 1 ED Medical IntakeHave you ever had an adverse or allergic reaction to ED medications?Cialis, Viagra, Stendra, Levitra, or any of its ingredients?YesNoContinue →Have you been advised to avoid strenuous exercise?YesNoProvide the reason:Continue →Is running or walking difficult for you?YesNoContinue →Do you have difficulty in getting or maintaining an erection?YesNoContinue →Do you have higher or lower than normal blood pressure?YesNoPlease explainContinue →Do you have a personal medical history involving any of the following medical conditions?Cardiovascular – heart attack, stroke, BP, arrhythmiaRespiratory-asthma, pulmonary hypertensionHematologic-bleeding or clotting disordersOpthalmic-Optic neuropathy, retinitisOtic-hearing lossAnatomical deformation of penis- increased risk of priapismNone of the aboveIf any selected, please explainContinue →Are you currently receiving Chemotherapy?YesNoContinue →Are you taking any of the following medications?Nitro, Nitrates or NitritesHIV Meds – protease inhibitorsRiociguat or other PDE inhibitorsNone of the aboveContinue →SHIMErectile Dysfunction severity indicator test Over the past 6 months. All fields are mandatory *How do you rate your confidence that you could get and keep an erection?Very LowLowModerateHighVery HighWhen you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?No sexual activityAlmost never or neverA few times (much less than half the time)Sometimes (about half the time)Most times (much more than half the time)Almost always or alwaysDuring sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?Did not attempt intercourseAlmost never or neverA few times (much less than half the time)Sometimes (about half the time)Most times (much more than half the time)Almost always or alwaysDuring sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?Did not attempt intercourseExtremely difficultVery difficultDifficultSlightly difficultNot difficultWhen you attempted sexual intercourse, how often was it satisfactory for you?Did not attempt intercourseAlmost never or neverA few times (much less than half the time)Sometimes (about half the time)Most times (much more than half the time)Almost always or alwaysSubmit →
Cialis, Viagra, Stendra, Levitra, or any of its ingredients?
Erectile Dysfunction severity indicator test Over the past 6 months. All fields are mandatory *
