What state do you live in?
We need this to match you with a licensed provider in your state.
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
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
Have you used ED medication before?
No, this is my first time
Yes, I have used ED medication
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.
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