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Medical History (Information provided below is protected by patient/physician privacy laws.
This and all the other information you have entered is encrypted and safe during
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Medical History:
Do you or any of your immediate family have a history of the following medical conditions?
Blood disorders e.g. anemia, hemophilia, hemochromatosis, phlebitis, sickle cell anemia, thalassemia, thrombosis, hypercholesterolemia, etc.
Cancer e.g. brain, breast, bladder, colorectal, endometrial, leukemia, lung, lymphoma, multiple myeloma, ovarian, prostate, skin, testicular, etc.
Cardiovascular disease e.g. angina, arrhythmia, atrial fibrillation, claudication, congestive heart failure, valve disorder, heart attacks, high blood pressure, strokes, etc.
Endocrine disorder e.g. diabetes, goiter, hyperthyroidism, hypothyroidism, pheochromocytoma, thyroiditis, etc.
Eye disorders e.g. cataracts, glaucoma, retinal complications, etc.
Gastrointestinal disorder e.g. acid reflux, hiatal hernia, irritable bowel syndrome (Crohn's disease, ulcerative colitis), polyps, rectal bleeding, ulcers, etc.
Genitourinary disorder e.g. benign prostatic hyperplasia, cysts, endometriosis, pelvic inflammatory disease, etc.
Immune disorders e.g. Hashimoto's disease, eczema, HIV, Graves disease, Sjogrens syndrome, sarcoidosis, sclerodoma, etc.
Kidney (urinary tract) disorder e.g. bladder disorders, cystic disease, glomerular disease, nephrotic syndrome, renal failure, urinary tract complications, etc.
Liver disorder e.g. cirrhosis, Gilbert's syndrome, hepatitis, hemochromatosis, Wilson's disease, etc.
Musculoskeletal e.g. arthritis, back/spine complications, fibromyalgia, gout, lyme disease, muscular dystrophy, myasthenia gravis, osteomalacia, osteoporosis, rickets, spinal cord injury, etc.
Neurological disorder e.g. Alzheimer's disease, epilepsy, head injuries, headaches, Huntington's disease, multiple sclerosis, seizure, etc.
Psychological disorder e.g. anxiety, attention deficit disorder, bipolar disorder, depression, obsessive compulsive disorder, panic disorder, post traumatic stress disorder, etc.
Respiratory disorder e.g. allergic rhinitis, asthma, chronic bronchitis, emphysema, tuberculosis etc.
Other e.g. acne, chemical dependency, menopause, nutritional disorder, obesity, pregnant/nursing, significant trauma, etc.
Do you have a history of any of the medical conditions previously mentioned including Blood disorders, Cancer, Cardiovascular disease, Endocrine disorder, Eye disorders, Gastrointestinal disorder, Genitourinary disorder Immune disorders, Kidney (urinary tract) disorder, Liver disorder Musculoskeletal, Neurological disorder, Psychological disorder, Respiratory disorder, Other conditions (not mentioned)? If yes, please explain. For example, duration of illness, any surgery or treatment (ten year history of  hypertension (high blood pressure), Atenolol 50mg one per day - well controlled with medications, Blood pressure 132/84):	Yes No
Do you have a history of any blood disorders e.g. sickle cell anemia, thalassemia, bleeding disorders, etc? If yes please explain:	Yes No

Additional Medical:
Currently, are you taking any medications (this includes over-the-counter or nonprescription medication, herbal supplements, sports supplements, etc.) or are you allergic to any medications, supplements or food products? If yes, please explain (medication, supplement including dosage and frequency or explain allergic reaction):	Yes No
Do you consume more than two servings of alcohol per day or use tobacco products? If yes, please quantify type of product and usage:	Yes No
Do you currently follow a routine exercise program? If yes, please quantify type and amount of exercise:	Yes No

Viagra Specific Questions:
ViagraŽ is contraindicated in individuals who are currently taking or have a history of taking any medication which contain nitrates, combining Viagra with nitrates can result in a dangerously low blood pressure that can result in a heart attack, stroke or even death. Are you currently taking any medications that contains nitrates or any medications that have nitro or isosorbide in their names? If yes please explain.	Yes No
Do you have an abnormal curvature of the penis (Peyronie's disease) or a history of priapism (painful/prolonged erection)? If yes please explain.	Yes No
ViagraŽ is prescribed for the treatment of erectile dysfunction. Our physicians will only prescribe Viagra for individuals that have some difficulty in this area. Do you have difficulties either achieving and/or maintaining an erection sufficient for sexual intercourse? If yes please explain.	Yes No
Have you ever been evaluated and subsequently treated for erectile dysfunction (injection therapy, vacuum pump, penile implant, etc.)? If yes please explain.	Yes No

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