Please Complete The Medical Questionnaire.

(N/A For Any Answers Unknown Or That Don’t Apply)

Question 1 : Name?

Question 2 : E-mail?

Question 3 : Date Of Birth?

Question 4 : Street Address?

Question 5 : City ?

Question 6 : State?

Question 7 : Zip Code?

Question 8 : Landline?

Question 9 : Cell Phone?

Question 10 : Sex?

Question 11 : Height?

Question 12 : Weight?

Question 13 : Emergency Contact Name?

Question 14 : Emergency Contact Relationship?

Question 15 : Emergency Contact Phone?

Question 16 : Are you experiencing Erectile Dysfunction(ED) or Premature Ejaculation(PE)?

Question 17 : Do you have any special needs?

Question 18 : What are your health concerns?

Question 19 : Please list any allergies you might have?

Question 20 : Please list any medications you are currently taking?

Question 21 : Please list any supplements you are currently taking?

Question 22 : List hospitalizations or surgeries you have had with corresponding dates?

Question 23 : Most recent Blood Pressure Reading - If not sure enter N/A?

Question 24 : Have you been diagnosed with any diseases or disorders and if so, when?

Question 25 : Any prior or current diagnosis of cancer?

Question 26 : Any prior or current diagnosis of type 1 diabetes?

Question 27 : Any prior or current kidney disease?

Question 28 : Any prior or current liver disease?

Question 29 : Any surgery within the last four (4) weeks?

Question 30 : Any surgery scheduled in the next three (3) months?

Question 31 : Date of most recent full physical exam?

Question 32 : Any abnormalities noted?

Question 33 : Date of most recent blood work?

Question 34 : Any abnormalities noted?

Question 35 : In the past 15 years have you had any heart problems??

Question 36 : Do you drink more than 2 alcoholic beverages per day?

Question 37 : Do you use any street or Recreational Drugs Poppers/Rush (butyl nitrite or armyl nitrite ?

Question 38 : Do you use any other Recreational drugs (not including marijuana) ?

Question 39 : Do you use Nitrates For Chest Pain?