- CosmeticRX

Please answer these questions accurately, as your Board-Certified internist will review these answers and determine if this medication is right for you.

How often do you have a problem having or maintaining an erection that is hard enough for sex?

Everytime Sometimes Rarely Other

How did your ED begin?

Gradually, but has worsened over time Suddenly, but not with a new partner Suddenly, with a new partner I do not recall how it began

Do you get erections when?

Masturbating When waking up Both when masturbating and when waking up I do not get erections, or very rarely get erections

Which of the following best describes your sex drive or desire to have sex (libido)?

Less than it was Less than it was because I know that I have trouble with erections Less, and it started before I had trouble with erections Less, but I don't know which came first (less desire or trouble with erections) My libido has not changed or has changed very little

In the last two weeks, have you been troubled by the following?

Feeling depressed, down, or hopeless, or having very little interest or pleasure in doing things Feeling nervous or anxious – to an extent that it impairs your ability at work or at home No, I have not felt depressed, overly anxious, or hopeless in the past 2 weeks

Have you been treated for ED previously? If Yes, please all all treatments, including medications or other treatments for ED that you have used or use currently (please state if this is prior use or current use)?

Yes, I have previously been treated for ED No, I have not previously been treated for ED

Please list all treatments, including medications or other treatments for ED that you have used or use currently (please state if this is prior use or current use)

Have you had a physical exam with a doctor within the past 3 years?

Yes No

Please list all of your current or past medical problems and surgeries?

Do you have diabetes? (If Yes, please list your most recent A1C or provide your most recent blood sugars)

Yes No

Please list your most recent A1C or provide your most recent blood sugars

Do you have high cholesterol?

Yes No

Do you have low blood pressure?

Yes No

Do you have high blood pressure – if yes, please state if your high blood pressure is adequately controlled?

Yes No

Please state if your high blood pressure is adequately controlled

Do you have any problems with your blood cells, such as sickle cell anemia, multiple myeloma or leukemia?

Yes No

Do you have any stomach ulcers?

Yes No

Do you have any liver problems, kidney problems or receive dialysis?

Yes No

Do you have or have you had a kidney transplant or any conditioning affecting the kidney?

Yes No

Do you have a spinal injury or paralysis?

Yes No

Do you have liver disease?

Yes No

Do you have a neurological condition?

Yes No

Do you have or have you had any life-threatening heart arrhythmias, abnormal heart beats or abnormal heart rhythms?

Yes No

Do you have a history of peripheral vascular disease?

Yes No

Do you have or have you had any acquired, congenital abnormalities of the heart, including heart murmurs?

Yes No

Do you have a history of idiopathic hypertrophic subaortic stenosis?

Yes No

Do you experience Chest pain or SOB when climbing 2 flights of stairs?

Yes No

Do you have any unexplained fainting or dizziness?

Yes No

Please list any current medications, vitamins or dietary supplements that you take, including the dosage?

Do you take any of the following medications? If yes, please list all of the medications from this list that you take? (A)

Nitroglycerin spray, ointment, patches or tablets (Nitro-Dur, Nitrolingual, Nitrostat, Nitromist, Nitro-Bid, Transderm-Nitro, Nitro-Time, Deponit, Minitran, Nitrek, Nitrodisc, Nitrogard, Nitroglycn, Nitrol ointment, Nitrong, Nitro-Par), Isosorbide mononitrate, or isosorbide dinitrate (Isordil, Dilatrate, Sorbitrate, Imdur, Ismo, Monoket), or any other medications containing nitrates?

Yes No

Please list all of the medications from this list that you take

Do you take any of the following medications? If yes, please list all of the medications from this list that you take? (B)

Alpha blockers, doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin) or Riociguat (Adempas), or any blood thinners?

Yes No

Please list all of the medications from this list that you take

Do you have any allergies? (including medication, food, herbal, or any other allergies?) If Yes – Please list your allergies

Yes No

Please list your allergies

Do you use any illegal drugs (if so, please provide the drug)

Yes No

Please provide the drug

Do you have, or have you ever had any of the following conditions? If yes, please list

Priapism (erection lasting longer than 6 hours), Retinitis Pigmentosa, Anterior Ischemic Optic Neuropathy, prior heart attack, stroke, or TIA

Yes No

Please list the conditions

Do you have a history of QT prolongation in you, or in your family history?

Yes No

Do you have any of the following conditions? If so, please list

A significant curve or bend in the penis that interferes with sex, Peyronie's disease, pain with erections or ejaculation, scarring, penile fracture, or any other issue with your penis?

Yes No

Please list the conditions

Do you have or have you had prostate cancer?

Yes No

Do you have or have you had an enlarged prostate (BPH)?

Yes No

Here you can type your first message to your physician; you can provide any additional information that you want them to know, or ask any questions that you have.

Yes, I want to provide additional info No, I do not want to provide any additional info

Please type your message to your physician

In your state, a telephone or video call is not required as part of telemedicine. If you would like a telephone call, please indicate that here

Yes, I would like to schedule a telephone call with my physician before they prescribe the medication No, I would not like to schedule a phone call

I understand that if I experience chest pain, dizziness, or nausea during sex, I will seek immediate medical help.

I acknowledge I do not acknowledge

I understand that if I have an erection that lasts for more than 4 hours, I will seek immediate medical attention.

I acknowledge I do not acknowledge

I understand that if I experience sudden vision loss in one or both eyes, this could be a sign of a serious eye problem, and I will stop taking Sildenafil or Tadalafil – depending on which product they have chosen in their order, and immediately seek medical attention.

I acknowledge I do not acknowledge

I understand that if I experience any sudden hearing loss or hearing change that I will stop taking Sildenafil or Tadalafil – this will depend on which product they have chosen, and seek immediate medical attention.

I acknowledge I do not acknowledge

Provide your most recent blood pressure reading (for example, 128/62, 132/58, 120/80), this must be from within the past 6 months – you can call your doctor's office to obtain your most recent blood pressure reading, or you can visit thousands of supermarkets and other stores nationwide and have your blood pressure checked, and then report this reading in the white box below

Have you previously been prescribed Sildenafil, and have had no side effects or very minimal side effects?

Yes - I have previously been prescribed sildenafil, and have had no, or very few minimal side effects No - I have previously experienced moderate or significant side effects with Sildenafil, or I have not previously taken this medication

I understand that I will inform my doctors and medical staff that I am taking this ED medication?

I understand I do not understand

I understand that the prescription can be adjusted between six refill options or paused or stopped at any time. The initial default refill frequency is every two months. Refills can be adjusted at any time by clicking refill settings in my dashboard.

I understand I do not understand

I understand that I can only take one type of ED medication at a time (Sildenafil or Tadalafil or any other ED medicine from CosmeticRx or another prescriber) within a 48 hour period.

I understand I do not understand

I ACKNOWLEDGE THAT BEFORE I START MY PRESCRIPTION, I WILL LOGIN AT CosmeticRx, AND READ THE PHYSICIAN CONSULTATION AND INSTRUCTIONS.

I acknowledge

All set. Thanks

You are not alone. Those with comparable symptoms often benefit from medication. We will now have one of the Board-Certified internists at CosmeticRx.com review your consultation.

CosmeticRx has the guaranteed lowest price of any US telehealth company for a 3 month (90 days) supply of .

How often do you have a problem having or maintaining an erection that is hard enough for sex?

How did your ED begin?

Do you get erections when?

Which of the following best describes your sex drive or desire to have sex (libido)?

In the last two weeks, have you been troubled by the following?

Have you been treated for ED previously? If Yes, please all all treatments, including medications or other treatments for ED that you have used or use currently (please state if this is prior use or current use)?

Have you had a physical exam with a doctor within the past 3 years?

Please list all of your current or past medical problems and surgeries?

Do you have diabetes? (If Yes, please list your most recent A1C or provide your most recent blood sugars)

Do you have high cholesterol?

Do you have low blood pressure?

Do you have high blood pressure – if yes, please state if your high blood pressure is adequately controlled?

Do you have any problems with your blood cells, such as sickle cell anemia, multiple myeloma or leukemia?

Do you have any stomach ulcers?

Do you have any liver problems, kidney problems or receive dialysis?

Do you have or have you had a kidney transplant or any conditioning affecting the kidney?

Do you have a spinal injury or paralysis?

Do you have liver disease?

Do you have a neurological condition?

Do you have or have you had any life-threatening heart arrhythmias, abnormal heart beats or abnormal heart rhythms?

Do you have a history of peripheral vascular disease?

Do you have or have you had any acquired, congenital abnormalities of the heart, including heart murmurs?

Do you have a history of idiopathic hypertrophic subaortic stenosis?

Do you experience Chest pain or SOB when climbing 2 flights of stairs?

Do you have any unexplained fainting or dizziness?

Please list any current medications, vitamins or dietary supplements that you take, including the dosage?

Do you take any of the following medications? If yes, please list all of the medications from this list that you take? (B)Alpha blockers, doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin) or Riociguat (Adempas), or any blood thinners?

Do you have any allergies? (including medication, food, herbal, or any other allergies?) If Yes – Please list your allergies

Do you use any illegal drugs (if so, please provide the drug)

Do you have, or have you ever had any of the following conditions? If yes, please listPriapism (erection lasting longer than 6 hours), Retinitis Pigmentosa, Anterior Ischemic Optic Neuropathy, prior heart attack, stroke, or TIA

Do you have a history of QT prolongation in you, or in your family history?

Do you have any of the following conditions? If so, please listA significant curve or bend in the penis that interferes with sex, Peyronie's disease, pain with erections or ejaculation, scarring, penile fracture, or any other issue with your penis?

Do you have or have you had prostate cancer?

Do you have or have you had an enlarged prostate (BPH)?

Here you can type your first message to your physician; you can provide any additional information that you want them to know, or ask any questions that you have.

In your state, a telephone or video call is not required as part of telemedicine. If you would like a telephone call, please indicate that here

I understand that if I experience chest pain, dizziness, or nausea during sex, I will seek immediate medical help.

I understand that if I have an erection that lasts for more than 4 hours, I will seek immediate medical attention.

I understand that if I experience sudden vision loss in one or both eyes, this could be a sign of a serious eye problem, and I will stop taking Sildenafil or Tadalafil – depending on which product they have chosen in their order, and immediately seek medical attention.

I understand that if I experience any sudden hearing loss or hearing change that I will stop taking Sildenafil or Tadalafil – this will depend on which product they have chosen, and seek immediate medical attention.

Have you previously been prescribed Sildenafil, and have had no side effects or very minimal side effects?

I understand that I will inform my doctors and medical staff that I am taking this ED medication?

I understand that the prescription can be adjusted between six refill options or paused or stopped at any time. The initial default refill frequency is every two months. Refills can be adjusted at any time by clicking refill settings in my dashboard.

I understand that I can only take one type of ED medication at a time (Sildenafil or Tadalafil or any other ED medicine from CosmeticRx or another prescriber) within a 48 hour period.

I ACKNOWLEDGE THAT BEFORE I START MY PRESCRIPTION, I WILL LOGIN AT CosmeticRx, AND READ THE PHYSICIAN CONSULTATION AND INSTRUCTIONS.

All set. Thanks

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Do you take any of the following medications? If yes, please list all of the medications from this list that you take? (B)

Alpha blockers, doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin) or Riociguat (Adempas), or any blood thinners?

Do you have, or have you ever had any of the following conditions? If yes, please list

Priapism (erection lasting longer than 6 hours), Retinitis Pigmentosa, Anterior Ischemic Optic Neuropathy, prior heart attack, stroke, or TIA

Do you have any of the following conditions? If so, please list

A significant curve or bend in the penis that interferes with sex, Peyronie's disease, pain with erections or ejaculation, scarring, penile fracture, or any other issue with your penis?