Top Health Center

Name *

Date of Birth *

Email *

Phone Number *

Address *

Sex *
Male Female Other

1 - Do you get nervous in certain situations? *

2 - What symptoms do you encounter leading up to these situations?*

Please briefly describe the situations and the symptoms you experience.

3 - Does this happen during sexual encounters?*

4 - Do you feel getting nervous/anxious is part of your life?*

5 - Do you feel performance anxiety impairs your full potential?*

6 - Have you tried any treatments in the past?*

Yes
No

7 - Was your past treatment effective?

Please also list the medication names and how long you used them (or if you are still using them). If you haven't tried any treatments, you can leave this question blank.

8 - Have you being diagnosed with high blood pressure? *

If yes, please list any medications you are taking.

9 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.

10 - Do you take any medicines, vitamins, or supplements?

Please list them here.

11 - 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.

12 - Is there anything else related to the treatment that you'd like to ask or discuss with your medical provider?

13 - Do you have a preferred treatment? *

No preference
Propranolol|(Generic Inderal®)

14 - Please enter preferred pharmacy information.*

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

Upload Past Medical Records *

Drop files here to upload

(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.