• 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14
  • 15
  • 16
  • 17
  • 18
  • 19
  • 20
  • 21
  • 22
  • 23
  • 24
  • 25

zip code

sex

What is your date of birth?

BLOOD PRESSURE IN LAST 6 MONTHS

Please enter a recent blood pressure taken within 6 months. If you have not had your blood pressure taken with the last 6 months or do not know your blood pressure, please call your doctor. Another great way to get a recent blood pressure reading is to stop by your local pharmacy. Most local pharmacies including, Walgreens, provide FREE blood pressure checks for people 18 years and older. It is important we have a recent blood pressure in order to asses medical safety. You should not take this medication if you have high blood pressure. Blood pressure should be checked yearly.

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?

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?

DO YOU HAVE ANY ALLERGIES?

TREATMENT OPTIONS

PLEASE ENTER YOUR PREFERRED PHARMACY INFORMATION HERE

payment details

Payment Information

Total Payment Value: $25.00