Let's Talk ED - No Shame, Just Solutions What is your email? Are you currently an active patient in Ness’ weight loss program? NoYes Would you like to bundle your ED medication with your medical weight loss prescription? NoYes How do you rate your confidence that you can get and keep an erection? Very lowLowModerateHighVery high When you have erections with sexual stimulation, how often are your erections hard enough for penetration? Almost never or neverA 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 neverA 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 DifficultVery DifficultDifficultSlightly DifficultNot difficult When you attempted sexual intercourse, how often was it satisfactory to you? Almost never or neverA 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 timeSuddenly, but not with a new partnerSuddenly, with a new partnerI don't know how it began Satisfied have you been with your overall sex life? Not at allA little bitSomewhatQuite a bitVery Which treatment option best fits your needs? Sildenafil (get hard fast)Tadalafil (stay hard longer) Have you ever taken ED medication before? NoYes Please list medication(s) previously tried: Have you ever been diagnosed with or treated for high or low blood pressure? NoYes, I have been diagnosed or treated for high blood pressureYes, I have been diagnosed or treated for low blood pressureI’m not sure Have you ever been diagnosed with any of these heart conditions? 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? None of these Organ transplant Kidney failure, disease, or dialysis Liver disease Retinitis Pigmentosa, a genetic condition that typically causes gradual changes in your vision Nonarteritic anterior ischemic optic neuropathy (NAION) Diabetes Nonarteritic anterior ischemic optic neuropathy (NAION) 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? No, I haven’t used these recreational drugs in the last 6 months Crystal meth (methamphetamines or amphetamines) Poppers or Rush Amyl Nitrate or Butyl Nitrate Cocaine Molly (MDMA, ecstasy) 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. Basic Information First Name Last Name Date of Birth Sex at Birth FemaleMale Phone 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. What type of consultation would you prefer? Email and Text Message (Fastest Option)VideoPhone Call How did you find Ness? 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 understand 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? Payment Information We'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. Card Number Expiration Date (MM/YY) Security Code Name on Card Referral Code (if applicable) Shipping Address Address Apartment, Suite, etc. (Optional) City State Zip Code Is your shipping address the same as billing? YesNo Billing Address Address Apartment, Suite, etc. (Optional) City State Zip Code
