What is your height (in inches)? What is your current weight (in lbs)? What is your month and year of birth? (MM/YY) Sex? male female
Are you taking any of the following?
Nitroglycerin	Nitrek (transdermal)	Nitro-Bid?
Nitrodisc	Nitro-Dur?	Nitrogard¢â
Nitroglyn	Nitrlingual Spray?	Nitrol?Ointment (Apoll-Kit)?
Nitrong	Nitro-Par	Nitrostar?
Nitro-Time	Transderm-Nitro?/font>	Isosorbide Mononitrate
Imdur?	Ismo?	Monoket?
Isosorbide Dinitrate	Dilarate?SR	Isordil?
Sorbitrate?	Erythatyl Tetranitrate	Pentaerythritol Tetranitrate
Sodium Nitroprusside
Do you have any of the following medical problems?
Coronary Artery Disease	Congestive Heart Failure	Valvular Heart Disease
Anatomic Deformation of the Penis	Peyronie's Disease	Multiple Myeloma
Obesity	Hypertension	Diabetes Mellitus
Prostate Cancer	Enlarged Prostate	Low Testosterone
Thyroid Disease	Atherosclerosis	Liver Disease
Kidney Disease	Stroke	Depression
Anxiety	Schizophrenia	Spinal Cord Injury
Endocrine Disorders	Sickle Cell Anemia	Leukemia
Have you had a complete physical exam with blood tests within the last year? yes no Do you consume more than 2 servings a day of alcohol? yes no If Yes Please explain: <> Do you smoke cigars or cigarettes? yes no What medications (if any) are you currently taking?

Sexual History:
Please indicate on this form your current medical problems.
It is the same information you would be asked if you visited
our clinic or any other physician that specializes in sexual
dysfunction. This and all the other information you have
entered is encrypted and safe during transmission over the
Internet. Once received by our physicians, it will be protected
under patient/doctor privilege law.
In the following questions, the term "erectile dysfunction"
means the inability to achieve or sustain an erection that
is adequate for normal sexual activity.

What is currently bothering you about your health?

Are you unable to achieve and sustain an erection that is adequate for penetration until orgasm? yes no Have you ever been evaluated for erectile dysfunction? yes no "I feel that I am incapable of having normal satisfying sex without prescription medication." true false