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FAQ

Admin

Viagra Consultation

We’ll need the general information regarding patient’s name, last street address, email address, day phone, all the other sites – and a list of yes-or-no questions:

I understand the potential side effects and have read the consumer information from Pfizer Pharmaceuticals regarding Viagra (yes or no)

I understand that I will be billed _________ for this consultation only if it is approved (yes or no)

I certify that all information I provide is truthful and complete.

Medical History

Date of Birth:

Height:

Weight:

Gender:

Allergies to Prescription Medications:

Current Medications:

Past Surgical History:

Have you had any of the following:

            Prostate Cancer

            Obesity

            Thyroid Disease

            Kidney Disease

            Anxiety

            Schizophrenia

            Depression

            Low Testosterone

            Heart Disease

            Diabetes

            Hypertension

            Prostatitis

            Enlarged Prostate

            Liver Disease

            Stroke

            Spinal Cord Injury

Have you ever been diagnosed with Attention Deficit Disorder (yes or no)

Are you currently being treated for Attention Deficit Disorder (yes or no)

Have you had a general physical examination and been found in good health, other than how as been previously noted (yes or no)

Do you suffer from high blood pressure (yes or no)

Do you smoke (yes or no)

Do you drink alcohol more than 2 ounces per day (yes or no)

Do you have any history of substance abuse (yes or no)

Do you take any prescription medication for the treatment of chest pain (yes or no)

Do you have shortness of breath or chest pain with exertion (yes or no)

Do you use any prescription medications that aren’t prescribed by a physician or other health care provider (yes or no) 

Do you have depression (yes or no)

Are you taking any nitroglycerine or nitroglycerine-derivative medications (yes or no)

Viagra is contraindicated in patients on nitroglycerine.  If you are on any of the medications listed below please indicate after reading list thoroughly: 

Nitro Dur

            Nitro Disc

            Nitro Bid

            Nitrek

            Minitran

            Deponit

            Nitrolingual Spray

            Nitro Ointment

            Nitrong

            Nitroglyn

            Nitro Par

            Nitrostat

            Nitrotym

            Transderm Nitro

Sexual History

What are your current issues with your sexual health?  Please list all concerns:

How long have you had a problem with this issue?

Do you have a problem achieving an erection (yes or no)

Do you loose your erection before or after penetration (before / after)

Have you ever been evaluated for erectile dysfunction (yes or no)

Have you ever seen a physician or other health care provider for male sexual dysfunction?  If so, please list any treatment intervention that may have been instituted, and when, whether it be oral medication, implants, injections, etc.: 

Dave, this should set-up the end of the Viagra consultation, other than the same financial information for payment processing.  And again, once we actually see it on-screen, I’m sure there will be some editing needed.  Thank you.