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Erectile Dysfunction Assessment
Medical & Health Questions
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Form Data:
Please answer these questions about your health and symptoms. This information helps us ensure your safety and provide appropriate treatment.
How would you rate the severity of your erectile dysfunction?
Mild - Sometimes have difficulty getting or maintaining an erection
Moderate - Often have difficulty getting or maintaining an erection
Severe - Almost always unable to get or maintain an erection
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 any heart conditions or cardiovascular disease?
Yes
No
Do you have high or low blood pressure?
Yes
No
Are you taking any nitrate medications (e.g., nitroglycerin)?
Yes
No
Are you taking blood thinners (e.g., warfarin, heparin)?
Yes
No
Have you tried ED treatments before?
Yes
No
Please list any other medications you're currently taking:
Do you have any allergies to medications?
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