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MEDICAL QUESTIONERE

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Sex

height in feet and inches

Weight in pounds

Is your Personal Healthcare Practitioner aware that you are requesting this medication ?

Have you had a physical exam in the last 12 months?

Are you currently under treatment for any health problems?

Are you using a nitrate drug for chest pain or heart problems.

Do you have heart disease or heart rhythm problems;

Is there any recent history (in the past 6 months) of a heart attack, stroke, or heart rhythm disorder;

Do you have high or low blood pressure;

Do you have coronary artery disease;

Do you have liver disease;

Do you have kidney disease;

Do you have a bleeding disorder such as hemophilia;

Do you have a stomach ulcer;

Have you have been told you should not have sexual intercourse for health reasons.

Please list all medications you are currently taking

Please list all medications that you plan to take while on this program

Please list all allergies

Please list any surgeries

Is there anything else in your medical history you deem relevant

Have you previously been treated for sexual dysfunction ?

I have read and agree to terms and conditions to use the site.