ED MIF - Medical Weight Loss Centers of America

Contact Information

This information is to verify your current details and is required for prescription purposes.

Name(Required)

First Last

Phone(Required)

(Please provide your most commonly used phone number as we use it to verify your identity)

Email(Required)

Enter Email Confirm Email

Address(Required)

Street Address Address Line 2 City State ZIP Code

What's the best method to contact you?

Health Information

Are you allergic to any medication?

What medications or vitamins are you taking?

Height

For Example: 5 ft 05 in OR 5 ft 10 in

Weight

In lbs

What is your date of birth?

Gender

Male

Female

Do you ever have a problem getting or maintaining an erection that is satisfying enough for sex? If you do not have a problem with an erection, you should not use our service. Which of the following apply to you?

Premature ejaculation, coming either before or shortly after sex (penetration) starts, can occur in some men. If this is the only problem you have with sex, you should see a doctor in person and not use our service. Which of the following apply to you?

How did your ED begin? Select the one that best describes your ED.

Do you get erections when masturbating?

Do you get erections when asleep or first thing in the morning?

Did your ED begin with a new sexual partner?

Enter your blood pressure reading taken within the last 6 months. For Example Systolic 120 / Diastolic 80

Please reenter your blood pressure

Have you had a physical exam by a doctor in the past 5 years? If you have not, we recommend you see a doctor before using our service. Select one of the following:

Did your physical exam include an exam of the genitals (including the testicles, penis)? If you have not, we recommend you see a doctor before using our service. Select one of the following:

The medicines we prescribe are only appropriate for certain patients. Which of the following best describes your sex drive or desire to have sex (libido)?

Over the past 2 weeks, how often have you been bothered by little interest or pleasure in doing things?

Over the past 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?

Over the past 2 weeks, how often have you been bothered by feeling nervous, anxious, or on edge?

Over the past 2 weeks, how often have you been bothered by worrying too much about different things?

ED can be related to tobacco, alcohol, or drug use. Select all that apply to you.

Smoke cigarettes or use other tobacco products

Drink more than 2 alcoholic beverages per day

Use a recreational drug called amyl nitrate or butyl nitrite (Poppers, Rush)

Use other recreational drugs

None apply

Some cases of ED are too complex for us to manage effectively online. Instead, you should see a doctor in person and not use our service. Do you have any of these conditions? Select all that apply to you.

Any condition where sex is not advised

Kidney problems including having had a kidney transplant

Liver problems

Neurological problems like multiple sclerosis or motor neuron disease

HIV

Spinal injury or paralysis

Previous surgery on your prostate or pelvis

Radiation therapy to your pelvis

None apply

Some genital issues can cause difficulty with sex and you should see a doctor in person and not use our service. Do you have any of these conditions? Select all that apply to you.

Physical abnormalities of the penis, curving or bending of the penis making it hard for sex, including Peyronie’s disease

Scarring of the penis. Feels like lumps or hard tissue under the skin

Pain with erections

Tight foreskin

None apply

It can be life-threatening to take ED medicines if you now HAVE or HAVE EVER had any of the following heart, blood pressure, or cardiovascular problems. Instead, you should see a doctor in person and not use our service. Select all that apply to you.

Certain symptoms can be a sign of a more serious medical problem and you should see a doctor in person and not use our service. When taken with ED medicines, these can cause a life-threatening problem. Select all that apply to you.

Chest pain or shortness of breath when climbing 2 flights of stairs or walking 4 blocks

Chest pain or shortness of breath with sexual activity

Unexplained fainting or dizziness

Cramping of the legs with exercise

Abnormal heartbeats or rhythms

None apply

ED can be the first sign of heart disease. Depending on your risk factors, you may need to see a doctor in person and not use our service. Which of the following additional risk factors do you have for heart disease? Select all that apply to you.

High cholesterol

My father had a heart attack or heart disease at 55 years or younger

My mother had a heart attack or heart disease at 65 years or younger

None apply

It can be life-threatening to take ED medicines if you now have or have ever had any of the following medical conditions. Instead you should see a doctor in person and not use our service. Select all that apply to you.

Priapism (erection lasting longer than 4 hours)

Retinitis pigmentosa

Anterior ischemic optic neuropathy (AION)

Sickle cell disease

Blood clotting disorder, abnormal bleeding or bruising, or coagulopathy

Myeloma or leukemia

Stomach or intestinal ulcer

None apply

It can be life-threatening to take ED medicines if you take any of the following medicines. Instead, you should see a doctor in person and not use our service. Select all that apply to you.

Nitroglycerin spray, ointment, patches or tablets (Nitro-Dur, Nitrolingual, Nitrostat, Nitromist, Nitrolingual, Nitro-Bid, Transderm-Nitro, Nitro-Time, Deponit, Minitran, Nitrek, Nitrodisc, Nitrogard, Nitroglyn, Nitrol ointment, Nitrong, Nitro-Par)

Isosorbide mononitrate or isosorbide dinitrate (Isordil, Dilatrate, Sorbitrate, Imdur, Ismo, Monoket)

Other medicines containing nitrates

Alpha blockers to treat high blood pressure or prostate problems, including doxazosin (Cardura), prazosin (Minipress), alfuzosin (Uroxatral), silodosin (Rapaflo), tamsulosin (Flomax), terazosin (Hytrin)

Sildenafil (Revatio) used to treat pulmonary hypertension

Riociguat (Adempas) used to treat pulmonary hypertension

None apply

Are you allergic to any medicines? Be sure to include any allergies to galactose, phenylalanine, or to any ED medicines, including but not limited to: avanafil (Stendra), sildenafil (Revatio / Viagra), tadalafil (Cialis), and vardenafil (Levitra, Staxyn).

Which of the following prescription ED medicines have you taken in the past, regardless of whether they worked well? SELECT ALL THAT APPLY TO YOU

Of the prescription ED medicines you just told us about, which ones worked to your satisfaction, regardless of whether you are currently taking them? SELECT ALL THAT APPLY TO YOU.

Did you have any side effects from your previous ED medicines that would stop you from using them again?

No, never taken ED medicines before

No, never had side effects that bothered me

Yes

Other than prescription medicines, have you used other treatments for ED in the past?

No, never used other treatments

Yes

Are you currently taking any other prescription medicines for other medical issues? Also include vitamins, herbs, and over-the-counter products, like pain relievers and sleep aids.

No, but I understand they are recommended tests

Yes

You can always access your medical record from your account screen. Would you like us to also mail a copy to your doctor?

Yes, please mail my medical record to my doctor

Finally, is there anything else we should know?

Hidden

Upload physical check up document

Drop files here or

Max. file size: 100 MB.

This field is for validation purposes and should be left unchanged.