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sex

What is your date of birth?

BLOOD PRESSURE IN LAST 6 MONTHS

HEART ATTACK IN LAST 6 MONTHS

HISTORY OF SEVERE CARDIAC DISEASE

HAS YOUR FATHER HAD A HEART ATTACK BEFORE THE AGE OF 55?

HAS YOUR MOTHER HAD A HEART ATTACK BEFORE THE AGE OF 65?

HISTORY OF SEVERE LIVER DISEASE OR LIVER FAILURE?

HISTORY OF SEVERE KIDNEY DISEASE OR KIDNEY FAILURE?

HISTORY OF PEPTIC ULCER DISEASE?

HISTORY OF BLEEDING DISORDERS?

CONGENITAL QT PROLONGATION

This is an abnormal heart rhythm you were born with

SPINAL CORD INJURY OR PARALYSIS?

PREVIOUS PROBLEMS WITH ED MEDICATIONS?

WHAT PROBLEMS?

HISTORY OF PEYRONIE'S DISEASE?

DO YOU HAVE ANY OF THE FOLLOWING? CHECK ALL THAT APPLY?

WHEN DID YOUR ED BEGIN?

HAVE YOU TRIED OTHER METHODS FOR ED?

WHICH ONES

ARE YOU CURRENTLY BEING TREATED FOR OTHER MEDICAL CONDITIONS?

WHAT MEDICATIONS ARE YOU TAKING? PLEASE INCLUDE OVER THE COUNTER MEDICATION AND HERBAL SUPPLEMENTS AND VITAMINS *DO NOT USE ED MEDICATIONS IF YOU ARE ALSO TAKING NITRATES

IS THERE ANYTHING ELSE WE SHOULD KNOW?

ARE YOU ALLERGIC TO MEDICATIONS?

TREATMENT OPTIONS

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Payment Information

Total Payment Value: $25.00