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Male Female Other

    1 - How often are you suffering from ED?*

  • Everytime
    Half the Time
    On Occassion
    Rarely

    • 2 - How often do you experience difficulty getting or maintaining an erection?*

  • Everytime
    Half the Time
    On Occassion
    Rarely
    Never

    • 3 - Pick the scenario that best describes your ED.*

  • Difficulty achieving Erections
    Difficulty Maintaining Erections
    Both

    • 4 - How did your ED start?*

  • Suddenly
    Gradually Worsened Overtime

    • 5 - Rate the typical hardness of your spontaneous erections in middle of the night or the morning.*

  • Penis does not enlarge
    Penis is larger, but not hard
    Penis is hard, but not hard enough for penetration
    Penis is hard enough for penetration, but not completely hard
    Penis is completely hard and fully rigid

    • 6 - Rate the typical hardness of your erection with a sexual partner.*

  • Penis does not enlarge
    Penis is larger, but not hard
    Penis is hard, but not hard enough for penetration
    Penis is hard enough for penetration, but not completely hard
    Penis is completely hard and fully rigid

    • 7 - Is your desire to have sex noticeably lower than it has been in the past?*

  • Yes
    No

    • 8 - Do you have a lack of energy?*

  • Yes
    No

    • 9 - Do you have a decrease in strength and/or endurance?*

  • Yes
    No

    • 10 - Have you ever been treated with medication for ED? If so, what was the name of the treatment?*


    • Please indicate if you are still using it, or for how long you used it.

    11 - What was your last blood pressure reading?*


    • You can find this information from a recent medical visit or by taking your blood pressure at a local pharmacy or grocery store. If you're not sure you can leave this blank.e indicate if you are still using it, or for how long you used it.

    12 - Do you experience any of the following cardiovascular symptoms?*

  • Chest pain when climbing two flights of stairs or walking four blocks
    Chest pain with sexual activity
    Unexplained fainting or dizziness
    Pain, ache, discomfort or fatigue after exercise that immediately improves with rest (such as pain in the calves, thighs, buttocks, hips or feet)
    Abnormal heart beats or rhythms
    None of these apply to me

    • 13 - Do you have or have you previously been diagnosed with any of the following?*

  • Prostate conditions
    Kidney diseases or conditions
    Liver, stomach, or other gastrointestinal conditions
    Nerve, spinal cord, or brain disorders
    Eye conditions or diseases
    Blood conditions or diseases
    Heart conditions or diseases
    Vascular conditions or diseases
    Penis conditions other than ED
    COVID-19
    Other chronic medical conditions
    None of these apply to me

    • 14 - Do any of the following apply to you?*

  • Peyronie's disease (acquired curve or bend in the penis that interferes with sex)
    Painful erections
    Broken or fractured penis
    Priapism (erection lasting longer than four hours)
    None of these applies to me

    • 15 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.*


    • Conditions, surgeries, or hospitalizations

    16 - Do you take any medicines, vitamins, or supplements?*


    • Medicines, vitamins, or supplements

    17 - Please list any allergies you have.*


    • Include any allergies to food, dyes, medications (including prescription medications and over-the-counter medications), insect venom, herbs, vitamins, supplements, and anything else.

    18 - Is there anything else related to the treatment that you'd like to ask to your medical provider?*


    • 19 - How many uses per month do you anticipate?*

  • 1-3 monthly uses
    4-6 monthly uses
    7-10 monthly uses
    11+ monthly uses

    • 20 - Do you have a preferred treatment?*


    • 21 - Do you have a preferred dose or strength?*


    • 22 - Do you have a preference on how often you'd like your medication?*

  • No preference
    Delivered monthly
    Delivered quarterly

    • 23 - Please enter preferred pharmacy information.*


    • Include a complete information where you would like to pick up your medication.

(Only JPEG, JPG, PNG or PDF format allowed and File size should be less than 10MB)

(Only JPEG, JPG, PNG or PDF format allowed and File size should be less than 10MB)

One Time Consulting Charges: $49.99 (USD)

The above payment is for consultation only and does not cover the cost of your medication. Top Health Center will only send your prescription to your pharmacy of choice.

Disclaimer
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