Let's start with your Information

On the following screens we will collect information about your health, medical history, and lifestyle.

Email Required!
Full Name Required!
Phone Number Required!
Day Required!
Month Required!
Year Required!
Gender Required!

How often are you suffering from ED?

What sort of results are you looking for?





Your Health

Your doctor needs to know about your symptoms and overall health to determine the most appropriate treatment for you. It's important that you provide accurate information.

We have some questions, please read carefully and answer then! It will take 5min!









Enter your blood pressure reading taken within the last 6 months?

Systolic Pressure (mmHG)
Diastolic Pressure (mmHG)

How often do you experience difficulty getting or maintaining an erection?

Pick the scenario that best describes your ED.





How did your ED start?









Rate the typical hardness of your erection during masturbation.

Rate the typical hardness of your spontaneous erections in the middle of the night or the morning.

Rate the typical hardness of your erection with a sexual partner.

Is your desire to have sex noticeably lower than it has been in the past?






Do you have a lack of energy?





Do you have a decrease in strength and/or endurance?





Are you sad and/or grumpy?









Have you ever been treated with medication for ED?







Which of the following treatments have you used to treat your ED in the past?

(You can select multiple medicines)

When was your most recent in-person checkup with a healthcare provider?

What was your last blood pressure reading?

Do you take any medications, vitamins, or supplements regularly?





Do you have any allergies?

Include any allergies to food, dyes, prescriptions, or over-the-counter medicines (e.g. antibiotics, allergy medications), herbs, vitamins, supplements, or anything else.





Have you had any surgeries or hospitalizations?