Let's Talk ED - No Shame, Just Solutions "*" indicates required fields Step 1 of 14 7% What is your email?* Are you currently an active patient in Ness’ weight loss program?* No Yes Would you like to bundle your ED medication with your medical weight loss prescription?*We highly recommend bundling with our medical weight loss program, as you can save up to 45% off your medication. No Yes How do you rate your confidence that you can get and keep an erection?* Very Low Low Moderate High Very High When you have erections with sexual stimulation, how often are your erections hard enough for penetration?* Almost never or never A few times (less than half the time) Sometimes (about half the time) Most times (more than half the time) Almost always or always How often are you able to maintain your erection for a long enough period to satisfy yourself or your partner?* Almost never or never A few times (less than half the time) Sometimes (about half the time) Most times (more than half the time) Almost always or always During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?* Extremely Difficult Very Difficult Difficult Slightly Difficult Not Difficult When you attempted sexual intercourse, how often was it satisfactory to you?* Almost never or never A few times (less than half the time) Sometimes (about half the time) Most times (more than half the time) Almost always or always How did you ED begin?* Gradually, but it worsened over time Suddenly, but not with a new partner Suddenly, with a new partner I don't know how it began How satisfied have you been with your overall sex life?* Not at all A little bit Somewhat Quite a bit Very Which treatment option best fits your needs?*Sildenafil (get hard fast)Tadalafil (stay hard longer)Have you ever taken ED medication before?* No Yes Please list medication(s) previously tried:* Have you ever been diagnosed with or treated for high or low blood pressure?* No Yes, I have been diagnosed or treated for high blood pressure Yes, I have been diagnosed or treated for low blood pressure I’m not sure Have you ever been diagnosed with any of these heart conditions? (Please check off all that apply)* None of these Arrhythmia Coronary artery disease (narrowing of the heart vessels) Coronary bypass surgery Heart attack Idiopathic Hypertrophic Subaortic Stenosis (aka hypertrophic obstructive cardiomyopathy) Long QT Syndrome Any congenital or developmental heart problems Pulmonary HTN (a rare condition that refers to the blood vessels to the lungs and isn't the same as high blood pressure) Heart failure Do you experience any of these symptoms? (Please check off all that apply)* None of these Chest pain while climbing stairs or walking Chest pain during sexual activity Sudden loss of vision due to loss of blood flow to your eye (aka anterior ischemic optic neuropathy) Unexplained fainting or dizziness Cramping or pain in the calves or legs with exercise (aka claudication) Have you ever been diagnosed with or experienced the following? (Please check off all that apply)* None of these Kidney failure, disease, or dialysis Liver disease Nonarteritic anterior ischemic optic neuropathy (NAION) Diabetes Told not to have sex for any reason Sickle Cell Anemia Stroke Peyronie’s disease or pain with erections Foreskin that’s too tight Active stomach, intestinal, or bowel ulcers or bleeding Bleeding disorder (causing you to bleed more easily than is normal) Multiple sclerosis, paralysis, or spinal cord injury Clotting disorder (you form clots more easily than is normal) Have you used any of these recreational drugs in the last 6 months? (Please check off all that apply)* Crystal meth (methamphetamines or amphetamines) Poppers or Rush Amyl Nitrate or Butyl Nitrate Cocaine Molly (MDMA, ecstasy) No, I haven’t used these recreational drugs in the last 6 months Please list all current medical conditions. Please type N/A if none.*Please list all of your known allergies. Please type N/A if none.* Do you currently use or have prescriptions for any of these medications?* None of these Any medication containing nitrates Any ALPHA blocker, NOT beta blocker (like Flomax, Cardura, and Minipress) Nitroglycerin in any form (Spray, tablet, patch, or ointment) Supplements that boost nitric oxide (like L-arginine, L-citrulline, beet root powder/extract/juice concentrate) Monoket (isosorbide mononitrate), Bidil, or Isordil (isorbide dinitrate), which are commonly prescribed to prevent chest pain caused by heart disease Antiretrovirals or any treatment for HIV Adempas (riociguat) Please list all prescriptions or over-the-counter medications and supplements you are currently taking. Please type N/A if none.* Tell Us About YourselfName* First Last Phone Number*Date of Birth* MM slash DD slash YYYY Sex at Birth* Female Male Please upload a government-issued form of ID (Driver’s License, Passport, etc.). Please be sure that your full name and photo are easily visible.*Max. file size: 5 MB.What type of consultation would you prefer?*Email and Text Message (Fastest Option)VideoPhone CallHow did you find Ness?* Consent*ED can be a sign of other undiagnosed medical issues like heart problems. Smoking, marijuana use, obesity, depression, and low testosterone can all play a role in erectile function (and dysfunction). In addition to seeking ED treatment, we recommend you speak with your primary care provider to rule out other underlying conditions. I understandConsent*Please attest to the following confirming that all the information you provided is true and complete. If you do not agree, you may not submit this form. I confirm that I am the patient completing this intake form and have reviewed all questions carefully. I attest that my answers are true, accurate, and complete to the best of my knowledge. I understand the importance of providing my doctor with complete and accurate health information for my care. I agree and consent Ness doctors review every form within 24 hours. Do you have any further information which you would like the doctor to know? One Last StepWe'll securely collect your payment information now, but you won't be charged until your intake form has been reviewed. If you qualify for medical weight loss, your first month’s prescription will be billed at that time. If you're not eligible, a $30 non-refundable evaluation fee will be charged to cover the cost of the medical review.Referral Code (if applicable)Shipping Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your shipping address the same as billing?* Yes No Billing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
