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Since these are prescription meds, we need to ask a few health questions.

Why we ask: Your answers help the licensed clinician determine if treatment is right for you.

Here's how it works:

  • Answer a few quick questions
  • Choose your treatment
  • Complete your order and checkout
You're charged only if the medication is shipped. If your doctor determines the treatment isn't right for you, your order will be canceled automatically and you'll receive a full refund—simple, secure, and stress-free.

Your privacy matters. All provided information is securely encrypted and accessible only by a licensed Canadian clinician and pharmacist, ensuring strict compliance with privacy and confidentiality regulations.

Erectile Dysfunction Questionnaire

When did your symptoms start?



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Erectile Dysfunction Questionnaire

What symptoms have you experienced in the last 12 months?



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Erectile Dysfunction Questionnaire

When do you experience these symptoms?



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Erectile Dysfunction Questionnaire

Do you get erections at night and/or when you wake up in the morning?



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Erectile Dysfunction Questionnaire

Have you ever experienced, or do any of the following apply to you?

Severe reactions may result if ED meds are used in conjunction with recreational drugs.



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Erectile Dysfunction Questionnaire

What heart or cardiovascular conditions have you had?



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Erectile Dysfunction Questionnaire

Have you had a heart attack in the last 3 months?



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Erectile Dysfunction Questionnaire

What diseases of the genitals or urinary symptoms have you had?



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Erectile Dysfunction Questionnaire

Are you currently using ED medication?



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Erectile Dysfunction Questionnaire

Have you ever taken medication or supplements for ED before?



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Erectile Dysfunction Questionnaire

How can we help today?



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Erectile Dysfunction Questionnaire

What’s the name of the medication you were taking?

Please provide any details related to the treatment, dosage and effectiveness.


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Erectile Dysfunction Questionnaire

Have you had a physical exam with a healthcare provider in the past 5 years?



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Erectile Dysfunction Questionnaire

Have you had blood work done in the last 2 years for ED?



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Erectile Dysfunction Questionnaire

What was your most recent blood pressure reading?



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Erectile Dysfunction Questionnaire

Do you experience any of the following cardiovascular symptoms?



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Erectile Dysfunction Questionnaire

Please tell us more about your prolonged leg cramps.



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Erectile Dysfunction Questionnaire

Tell us about your lifestyle.

Understanding your lifestyle helps us provide you with the highest possible level of care.



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Erectile Dysfunction Questionnaire

What recreational drugs do you use?



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Erectile Dysfunction Questionnaire

Do you have kidney or liver problems?



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Erectile Dysfunction Questionnaire

Please list any surgeries or hospitalizations. If none, please continue.



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Erectile Dysfunction Questionnaire

Do you have any other information or questions for the doctor?



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Erectile Dysfunction Questionnaire

PDE5i Consent



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Acknowledgement

Pharmacy Consent