Intake Form – Erectile Dysfunction – Tadalafil

Tell Us About Yourself
In order to receive your prescription, please answer these questions for our physician:

1. Personal Health Info

How did your ED begin? Select the one that best describes your ED.

On a scale from 1 to 5, how satisfied have you been with your sex life in the past six months?

On a scale from 1 to 5, how would you rate your partner’s satisfaction with your sex life together?

How satisfied have you been with the hardness of your erections over the past six months?

On a scale from 1 to 5, how would you rate your self-confidence over the past six months?

How satisfied have you been with your ability to get an erection whenever you wanted over the past six months, in general?

On a scale from 1 to 5, how would you rate the way you feel about your body over the past six months?

Have you ever been formally treated for ED or tried any medicines, vitamins, or supplements to treat it?

Do you ever have a problem ejaculating sooner than you or your partner would like?

Have you been diagnosed with or treated for high or low blood pressure?

Do you have any medical conditions or a history of prior surgeries?*

Do any of the following cardiovascular risk factors apply to you?

In the last 2 weeks, have you been bothered by any of the following?

Do you currently have, or have you ever experienced, any of the following?

Do you have any of these conditions?

Do you have any of the following symptoms related to your heart or blood vessels?

Do you currently have, or have you ever experienced, any of the following? Select all that apply.

Which of the following apply to you?

Do you currently use, or have an active prescription for, any of the following?

Have you used any of the following recreational drugs in the past 6 months?

Knowing your race and/or ethnic background helps us work toward improving equally accessible, high quality care for everyone on our platform.

Do you have any allergies to prescription or over-the-counter medicines, herbs, vitamins, supplements, food, dyes, or anything else? Our clinicians use this information in determining a safe and effective treatment.

Do you take any prescriptions and over-the-counter medications, herbs, minerals, inhalers, injections, and medication implants or patches? Do not include any medications that Simple RX is prescribing. Our clinicians use this information in determining a safe and effective treatment.

What supply are you looking for?

2. Information for Pharmacy

Address

Street Address

Street Address Line 2

State

Zip Code

3. Contact Information

Name

Best Email

Phone Number

Your Medical Care

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