Dripology - Sildenafil (Viagra)

What state do you live in?

We need this to match you with a licensed provider in your state.

What is your current height and weight?

Required by the prescribing physician.

Weight (pounds) Height

Feet

Inches

Your BMI Result

Underweight <18.5 Normal 18.5-24.9 Overweight 25-29.9 Obese ≥30

How would you describe your erectile dysfunction?

This helps us determine the right treatment for you

I can never get an erection

I can get an erection but can't maintain it

I occasionally have difficulty

I want to improve my performance

How long have you been experiencing these symptoms?

Less than 3 months

3-6 months

6-12 months

More than 1 year

Do you have higher or lower than normal blood pressure?

No

Yes

What is your most recent blood pressure reading?

You can check at a pharmacy or with a home monitor

Do any of these apply to you?

These conditions may affect your eligibility for ED medication

None of the below

Heart attack in the last 90 days

Stroke in the last 6 months

Unstable angina or chest pain during sexual activity

Heart failure

Uncontrolled high blood pressure

Low blood pressure (below 90/50)

Heart arrhythmia

History of heart surgery, stenting, or bypass

Based on your selection, you may not be eligible for this treatment. A provider will review your information and follow up with you.

Do you take any nitrate medications?

This is critically important — nitrates combined with ED medication can cause a dangerous drop in blood pressure

None of the below

Nitroglycerin (tablets, patches, or spray)

Isosorbide mononitrate (Imdur)

Isosorbide dinitrate (Isordil)

Amyl nitrite or "poppers" (recreational)

Based on your selection, you may not be eligible for this treatment. A provider will review your information and follow up with you.

Do you take any of these prostate or blood pressure medications?

These may require a lower starting dose

None

Tamsulosin (Flomax)

Doxazosin (Cardura)

Terazosin (Hytrin)

Alfuzosin (Uroxatral)

Prazosin (Minipress)

Do any of these apply to you?

These conditions increase the risk of priapism (prolonged erection)

None of the below

Sickle cell disease

Multiple myeloma

Leukemia

Peyronie's disease (penile deformity)

History of priapism (erection lasting over 4 hours)

Based on your selection, you may not be eligible for this treatment. A provider will review your information and follow up with you.

Have you experienced any of the following?

These may affect your eligibility

None of the below

Sudden loss of vision in one or both eyes

Non-arteritic anterior ischemic optic neuropathy (NAION)

Retinitis pigmentosa

Sudden decrease or loss of hearing

Based on your selection, you may not be eligible for this treatment. A provider will review your information and follow up with you.

Do you have any liver or kidney conditions?

No

Mild liver or kidney issues

Severe liver or kidney disease

Based on your selection, you may not be eligible for this treatment. A provider will review your information and follow up with you.

Are you currently taking any medications?

Include prescriptions, supplements, and over-the-counter medications

No, I don't take any medications

Yes, I take medications

Please list all current medications

Include HIV medications, antifungals, blood thinners, and any supplements

Have you used ED medication before?

No, this is my first time

Yes, I have used ED medication

Which ED medication were you on?

Sildenafil (Viagra)

Tadalafil (Cialis)

Other / not sure

What dose were you taking?

25 mg

50 mg

100 mg

What dose were you taking?

2.5 mg daily

5 mg daily

10 mg as needed

20 mg as needed

How well did it work for you?

Worked great

Partially — could be better

Didn't work

Had side effects and stopped

Has a doctor ever told you that sexual activity is unsafe for you?

No

Yes

Based on your selection, you may not be eligible for this treatment. A provider will review your information and follow up with you.

Sexual Health Inventory for Men (SHIM) — pick the range that best describes you

The SHIM is a 5-question instrument scored 5–25; lower scores indicate more severe ED. Pick the range that matches your overall confidence and ability over the past 6 months.

22–25 — no ED

17–21 — mild ED

12–16 — mild-to-moderate ED

8–11 — moderate ED

5–7 — severe ED

Is running or walking difficult for you?

Cardiovascular fitness affects whether sexual activity is safe at typical exertion levels.

No

Yes

Are you currently receiving chemotherapy?

No

Yes

Have you ever had an adverse or allergic reaction to ED medications or their ingredients?

No

Yes

Based on your selection, you may not be eligible for this treatment. A provider will review your information and follow up with you.

Anything else you'd like your doctor to know?

Share any additional information, questions, or concerns.

This is optional - only include what you think is important

Upload a photo of the front of your government-issued ID.

Driver's license, state ID, or passport. Required for prescriber identity verification.

📸

Tap to take or upload a photo
(JPG, PNG, WEBP, or PDF — HEIC not supported)

Upload a selfie holding your ID.

Hold your ID up next to your face so your prescriber can confirm the ID is yours.

📸

Tap to take or upload a photo
(JPG, PNG, WEBP, or PDF — HEIC not supported)