ED Health Screening

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Clearance Medication

First up,answer a few questions so we can help.

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Let's start with your name.(Required)

First Last

What is your email?(Required)

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What is the best number to reach you(Required)

Consent(Required)

I agree to receive automated updates and promotional texts from Regenics at this number. Consent is not required for purchase. Msg & data rates may apply. Reply STOP to opt out. View our Privacy Policy and Terms.(Required)

Is this treatment for you or someone else?(Required)

Myself

Someone else

This intake pertains to the patient. If you are assisting someone else, please answer the questions with the patient's information and history.

What was your assigned sex at birth?

Male

Female

We want to make it easy on you. Which consultation method would you prefer?(Required)

An Online Questionnaire Consultation (Fastest, no additional consultation needed)

A Phone Consultation

What's your date of birth?(Required)

Month

Day

Year

Let's pair you with a licensed provider in your state. What state do you live in?(Required)

Consent(Required)

I agree to the Terms and Conditions and Telehealth Consent and I acknowledge the Privacy Policy.(Required)

How are you looking to improve your sex life?(Required)

Get harder

Last longer

Both

Do you have any allergies or medication reactions?(Required)

Yes

This includes any allergies to food, dyes, prescriptions, or over-the-counter medications, herbs, vitamins, supplements, or anything else.

Please list what you are allergic to.(Required)

Do you experience chest pain, chest tightness, or severe lightheadedness when you walk a mile or have sex?(Required)

Yes

Explain the symptoms you get with walking or sex in as much detail as you can.(Required)

Have you ever been diagnosed with or prescribed medication for any medical issues?(Required)

Yes

Have you ever been diagnosed with or prescribed medication for any of the following conditions?(Required)

Abnormal blood pressure, diabetes, or high cholesterol

Blood or immune system disorders (including HIV)

Gastrointestinal, stomach, or liver disorders

Kidney problems

Circulation problems with arteries or veins

Eye conditions or diseases

Penis or prostate conditions (other than ED)

Brain, spinal cord, or nerve problems (including stroke)

Mental health or psychiatric conditions

Other chronic medical conditions

None of these

What other chronic medical conditions have you ever been diagnosed with or prescribed medication?(Required)

Which of these have you experienced?(Required)

Diabetes

High blood pressure

Low blood pressure

High cholesterol

Other

You said: Abnormal blood pressure, diabetes, or high cholesterol

Please tell us more about your blood pressure, diabetes, or cholesterol condition.(Required)

Do you take any medications to manage your diabetes?(Required)

Yes

Which medication(s) do you take to manage your diabetes?(Required)

Canagliflozin (Invokana)

Empagliflozin (Jardiance)

Glimepiride (Amaryl)

Glipizide (Glucotrol, Glucotrol XL)

Glyburide (Diabeta, Glynase, Micronase)

Insulin (any type)

Linagliptin (Tradjenta)

Metformin (Glucophage, Riomet, Glumetza, Fortamet)

Pioglitazone (Actos)

Saxagliptin (Onglyza)

Sitagliptin (Januvia)

Something else

What other medication(s) do you take to manage your diabetes?(Required)

Do you take any medications to manage your high blood pressure?(Required)

Yes

What medication(s) do you take to manage your high blood pressure?(Required)

Amlodipine (Norvasc)

Atenolol (Tenormin)

Carvedilol (Coreg)

Clonidine (Catapres)

Furosemide (Lasix)

Hydrochlorothiazide (Hydrodiuril, Microzide)

Lisinopril (Prinivil, Zestril)

Losartan (Cozaar)

Metoprolol (Lopressor, Toprol XL)

Spironolactone (Aldactone)

Something else

What other medication(s) do you take to manage your high blood pressure?(Required)

Which of these have you experienced?(Required)

Blood conditions or diseases

HIV/AIDS

Other

You said: Blood or immune system disorders

Please tell us more about your blood or immune system condition.(Required)

Include the diagnosis and treatment.

Which of the following blood conditions do you have?(Required)

Sickle cell anemia, Myeloma, Leukemia

Blood clotting disorder, abnormal bleeding or bruising, or coagulopathy

Other

Please tell us more about your blood condition.(Required)

Include the diagnosis and treatment.

Please tell us more about your sickle cell anemia, myeloma, or leukemia.(Required)

Please tell us more about your blood clotting disorder, abnormal bleeding or bruising, or coagulopathy.(Required)

Do you take any medications to manage your HIV/AIDS?(Required)

Yes

What medication(s) do you take to manage your HIV/AIDS?(Required)

Aptivus / tipranavir (TPV)

Atazanavir / ritonavir (ATV-r)

Crixivan / indinavir (IDV)

Darunavir / ritonavir (DRV-r)

Evotaz / atazanavir/cobicistat (ATV-c)

Genvoya (Elvitegravir/Cobicistat/ Emtricitabine/Tenofovir alafenamide)

Invirase / saquinavir (SQV)

Lexiva / fosamprenavir (FPV)

Kaletra / lopinavir/ritonavir (LPV)

Norvir / ritonavir (RTV)

Prezcobix / darunavir/cobicistat (DRV-c)

Reyataz / atazanavir (ATV)

Stribild (Elvitegravir/Cobicistat/ Emtricitabine/Tenofovir disoproxil fumarate)

Symtuza (darunavir/cobicistat/emtricitabine/tenofovir alafenamide)

Tybost / cobicistat

Other

All Medications

What other medication(s) do you take to manage your HIV/AIDS?(Required)

Which of these have you experienced?(Required)

Liver disease or conditions

Stomach or other gastrointestinal conditions

You said: Gastrointestinal, stomach, or liver disorders

Do you currently have any of the following liver diseases or conditions?(Required)

Cirrhosis

Fatty liver

Hepatitis

Liver transplant

Other liver disease

Please tell us more about your liver disease.(Required)

Include the diagnosis and treatment.

Please tell us more about your liver problems.(Required)

My liver function is normal or mildly impaired

My liver function is poor

I don't know

Please tell us more about your liver problems.(Required)

Include the diagnosis and treatment.

When was your liver transplant?(Required)

Less than 3 months ago

More than 3 months ago

Is your transplant functioning well?(Required)

Yes

Which of the following stomach or gastrointestinal conditions do you have?(Required)

Stomach or intestinal ulcer

Other

Please tell us about any stomach or gastrointestinal conditions you have.(Required)

Include the diagnosis and treatment.

There have been postmarketing reports of GI bleeding after PDE5i treatment in men with gastrointestinal ulcers. However, it is not known if bleeding was caused by PDE5i in these cases.(Required)

I understand these risks and would like to continue

Do you want to continue?

Which of these have you experienced?(Required)

Kidney stones

End-stage renal disease on dialysis

Kidney transplant

Chronic kidney disease

Other

You said: Kidney problems

Please tell us more about your kidney condition.(Required)

When was your kidney transplant?(Required)

Less than 3 months ago

More than 3 months ago

Which of the following represents your kidney disease?(Required)

Stage 1-2

Stage 3-4

I'm not sure

Which of these have you experienced?(Required)

Peripheral vascular disease (aka peripheral arterial disease)

Vascular or aortic aneurysms

Other

You said: Circulation problems with arteries or veins

Please tell us more about your circulation condition with arteries or veins.(Required)

Include the diagnosis and treatment.

Have you been evaluated by your healthcare provider for peripheral vascular disease after initial diagnosis?(Required)

Yes

Are you following the treatment recommendations (if any) that were made by that provider?(Required)

Yes

Please tell us more about your vascular or aortic aneurysms.(Required)

Which of these have you experienced?(Required)

Retinitis Pigmentosa

Anterior Ischemic Optic Neuropathy (AION)

History of sudden vision loss in one or both eyes

Central serous chorioretinopathy

Other

You said: Eye conditions or diseases

Please tell us more about your other eye condition.(Required)

Include the diagnosis and treatment.

Please tell us more about your retinitis pigmentosa.(Required)

Please tell us more about your Anterior Ischemic Optic Neuropathy (AION).(Required)

Please tell us more about your history of vision loss.(Required)

Please tell us more about your central serous chorioretinopathy.(Required)

Which of these have you experienced?(Required)

Prostate conditions

Penis conditions other than ED

Other urology conditions

You said: Penis or prostate conditions

Please tell us more about your urology condition.(Required)

Include the diagnosis and treatment.

Which of the following prostate conditions do you have?(Required)

Prostate cancer

Enlarged prostate (BPH)

Other prostate condition

Please tell us more about your prostate condition.(Required)

Include the diagnosis and treatment.

Please tell us more about your prostate cancer.(Required)

Please tell us more about your enlarged prostate.(Required)

Which of the following penis conditions other than ED do you have?(Required)

Peyronie's disease (acquired curve or bend in the penis that interferes with sex)

Painful erections

Broken or fractured penis

Priapism (erection lasting longer than 4 hours)

Other

Please tell us more about your penis conditions other than ED.(Required)

Does the mark or curve prevent you from having sex? Is it painful? Have you sought treatment for this? If so, what kind of treatment did you receive?(Required)

Please tell us more about your painful erections.(Required)

Please tell us more about your broken or fractured penis.(Required)

Please tell us more about your priapism.(Required)

Which of these have you experienced?(Required)

Stroke, mini stroke or TIA

Partial or complete paralysis from a neck or back injury

Other neurological disease

You said: Brain, spinal cord or nerve problems (including stroke)

Please tell us more about your other neurological condition.(Required)

Include the diagnosis and treatment.

What spinal cord level was your neck or back injury?(Required)

T6 or higher (C1-7 or T1-5)

T7 or lower (T7-T12, L1-L6)

Have you been evaluated by your healthcare provider for your stroke, mini stroke, or TIA after initial diagnosis?(Required)

Yes

Are you following the treatment recommendations (if any) that were made by that provider?(Required)

Yes

Which of the following mental health or psychiatric conditions do you have?(Required)

Depression

Generalized anxiety disorder

Bipolar disease

Schizophrenia

Panic disorder

Other

Please tell us more about your mental health or psychiatric condition.(Required)

Include the diagnosis and treatment.

Do you take medication to manage your mental health or psychiatric condition?(Required)

Yes

What medication(s) do you take to manage your mental health or psychiatric condition?(Required)

Do you have or have you previously been diagnosed with any of the following heart conditions?(Required)

Abnormal heart beats or rhythms

Implanted internal cardioverter defibrillator (ICD)

Congestive heart failure

Coronary artery disease (without prior heart attack)

Coronary bypass surgery

Coronary angioplasty/stent

Heart attack

Idiopathic Hypertrophic Subaortic Stenosis (hypertrophic obstructive cardiomyopathy)

Long QT Syndrome (QT Prolongation)

Other electrical heart abnormalities

None of these

Please tell us more about your other heart abnormalities.(Required)

What type of heart arrhythmia (abnormal heart beats) or heart-related diagnosis do you have?(Required)

Have you been admitted to the hospital or had an emergency room visit related to heart failure within the past year?(Required)

Yes

When was your most recent heart attack?(Required)

Less than 3 months ago

3-6 months ago

More than 6 months ago

Do you take any medications, vitamins, or supplements regularly?(Required)

Yes

Be sure to select yes if you take prescription medication for any chronic medical condition (such as high blood pressure, high cholesterol or diabetes).

Do you take medication to keep your cholesterol low?(Required)

Yes

What medication do you take to lower your cholesterol?(Required)

Do you take any of the following medications?(Required)

Nitroglycerin spray, ointment, patches or tablets (e.g. 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 (e.g. Isordil, Dilatrate, Sorbitrate, Imdur, Ismo, Monoket)

Nitric Oxide supplements/boosters

Non-uroselective alpha blockers (e.g. doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin))

Uroselective alpha blockers (e.g. Flomax (tamsulosin), Uroxatral (alfuzosin), and Rapaflo (silodosin))

Riociguat (Adempas)

Any of the following heart medications: amiodarone (Cordarone, Pacerone), sotalol (Betapace, Sorine, Sotylize), dofetilide (Tikosyn), ibutilide (Corvert), Dronedarone (Multaq), quinidine (Quinaglute, Quinidex), procainamide (Pronestyl, Procan, Procanbid), disopyramide (Norpace, Rythmodan)

None of these

Please list the name of the Nitric Oxide supplement/booster you are taking.(Required)

Which non-uroselective alpha blocker are you taking?(Required)

Doxazosin (Cardura)

Prazosin (Minipress)

Terazosin (Hytrin)

Something else

What other non-uroselective alpha blocker are you taking?(Required)

Which uroselective alpha blocker are you taking?(Required)

Flomax (tamsulosin)

Uroxatral (alfuzosin)

Rapaflo (silodosin)

Something else

What other uroselective alpha blocker are you taking?(Required)

Which heart medication are you taking?(Required)

Amiodarone (Cordarone, Pacerone)

Sotalol (Betapace, Sorine, Sotylize)

Dofetilide (Tikosyn)

Ibutilide (Corvert)

Dronedarone (Multaq)

Quinidine (Quinaglute, Quinidex)

Procainamide (Pronestyl, Procan, Procanbid)

Disopyramide (Norpace, Rythmodan)

Something else

What other heart medication are you taking?(Required)

Please list any other current medicines, vitamins, or dietary supplements you take regularly that you haven't already told us about.(Required)

Include exact names of any medicines (e.g. Lipitor, Zyrtec, Ibuprofen)

Hidden

*This question is hidden to patients. Patient is only required to report BP if any of the following are true: *

Age > 50

Medical conditions

Previously diagnosed with high or low BP

None of the above - Patient is not required to report BP (unless patient fails screening question for symptoms of abnormal BP)

When was the last time you or a healthcare provider checked your blood pressure?(Required)

Within the last 18 months

More than 18 months ago

We will need you to take your blood pressure at a local pharmacy, grocery store, or with a healthcare provider.(Required)

Got it, I will get a new blood pressure measurement and report it to Regenics when I get the chance.

Hidden

What was your last blood pressure reading?

Less than 90/less than 50

Less than 90/50-80

Less than 90/81-89

Less than 90/100 or higher

90-139/less than 50

90-139/50-80

90-139/81-99

90-139/100 or higher

140-169/less than 50

140-169/50-80

140-169/81-99

140-169/100 or higher

170 or higher/less than 50

170 or higher/50-80

170 or higher/81-99

170 or higher/100 or higher

I dont remember

What was your last blood pressure reading?(Required)

Less than 90 or higher than 140/Less than 50 or higher than 100

90-140/50-100

I don't remember

Did your healthcare provider say any of the following about your blood pressure at your last visit?(Required)

My provider definitely checked my blood pressure and told me that it was normal.

My provider expressed concern about my blood pressure.

I don’t remember discussing my blood pressure with my provider.

In the last 3 months have you experienced any of the following?(Required)

Yes

Fainting, almost fainting, severe headaches, blurry or double vision, recurrent nosebleeds.

To continue, we need your latest blood pressure.(Required)

Got it, I will get a new blood pressure measurement and report it to Regenics when I get the chance.

You can get this at a local pharmacy, grocery store, or with a healthcare provider.

To continue, we need your latest blood pressure.(Required)

Got it, I will get a new blood pressure measurement and report it to Regenics when I get the chance.

You can get this at a local pharmacy, grocery store, or with a healthcare provider.

Do you currently or have you ever regularly used tobacco products?(Required)

Yes, I use tobacco products on some or most days

Yes, I previously used tobacco products but quit

No, I have never regularly used tobacco products

Have you smoked, ingested or used any of the following within the past 6 months?(Required)

Poppers or Rush (Amyl Nitrate or Butyl Nitrate)

Cocaine

Methamphetamine (crystal meth)

Other

None of these

Can you tell us what other recreational drug(s) you use?(Required)

Please include how frequently and the last time you used it.

How often have you used Poppers or Rush (Amyl Nitrate or Buyl Nitraye) in the last 6 months?(Required)

Once or twice

Three or more times

Are you willing to and capable of stopping Poppers or Rush (Amyl Nitrate or Buyl Nitrate) use while you are on our medication?(Required)

Yes

The combination of poppers or rush with oral medications for ED can cause *life and health threatening low blood pressure*. These potentially fatal effects are caused by the combined effects of poppers/rush and ED medications on your heart and blood vessels. Some of the emergencies that can occur when poppers or rush and ED medications are combined include the following: light-headedness, fainting, shock (not enough blood flow to all parts of your body), death.(Required)

I have read the provided warning about the risks of serious medical harm and/or death if I use poppers or rush and ED medications together.

How often have you used cocaine in the last 6 months?(Required)

Once or twice

Three or more times

Are you willing to and capable of stopping cocaine use while you are on our medication?(Required)

Yes

The combination of cocaine with oral medications for ED can cause *serious life and health threatening emergencies.* Some of the emergencies that can occur when cocaine and ED medications are combined include the following: priapism (an erection that doesn't go away and can cause permanent damage to your penis), stroke (which can cause permanent disability), cardiac arrest (your heart stops beating), muscle rigidity, very high fever, death.(Required)

I have read the provided warning about the risks of serious medical harm and/or death if I use cocaine and ED medications together

How often have you used Methamphetamine (crystal meth) in the last 6 months?(Required)

Once or twice

Three or more times

Are you willing to and capable of stopping methamphetamine use while you are on our medication?(Required)

Yes

The combination of methamphetamine (crystal meth) with oral medications for ED has been associated with high risk behavior and transmission of sexually transmitted diseases.(Required)

I have read the provided warning about the higher risks of acquiring or transmitting a sexually transmitted disease that are associated with using crystal methamphetamine and ED medications at the same time. I understand that risk and agree that I will not use ED medications and crystal methamphetamine at the same time.

Have you ever been treated with medication for ED?(Required)

Yes

When was the last time you took medication to help improve your sex life?(Required)

Less than two years ago

More than two years ago

I'm not sure

Which of the following treatments have you used to treat your ED in the past?(Required)

Sildenafil (Viagra or generic)

Tadalafil (Cialis or generic) - every day

Tadalafil (Cialis or generic) - only before sexual activity

Vardenafil (Levitra or generic)

Avanafil (Stendra)

Other

Please tell us more about your usage of other ED treatments. Which dosages did you try? Were they effective?(Required)

How often you take Tadalafil in a month?(Required)

Daily

4 times in a month

8 times in a month

12 times in a month

16 times in a month

How often you take Sildenafil in a month?(Required)

Daily

4 times in a month

8 times in a month

12 times in a month

16 times in a month

Hidden

1What is the highest dose of Sildenafil (Viagra or generic) day you took?

20mg

25mg

40mg

50mg

60mg

80mg

100mg

What is the highest dose of Sildenafil (Viagra or generic) day you took?(Required)

20mg

50mg

100mg

Hidden

1Were you happy with your treatment with Sildenafil (Viagra or generic) ?

Yes, I would attempt this medication again at the same dose

Yes, but I would like to try a higher dose

Yes, but I would like to try a lower dose

No, I would prefer to try another medication

Were you happy with your treatment with Sildenafil (Viagra or generic) ?(Required)

Yes, I would attempt this medication again at the same dose

Yes, but I would like to try a higher dose

Yes, but I would like to try a lower dose

No, I would prefer to try another medication

Why were you not happy with your treatment with Sildenafil (Viagra or generic) ?(Required)

It didn't work

I had side effects

Both

Were your side effects intolerable?(Required)

Yes

Please tell us more about the side effects you experienced.(Required)

Hidden

What is the highest dose of Tadalafil (Cialis or generic) that you took every day?

2.5mg

5mg

What is the highest dose of Tadalafil (Cialis or generic) that you took every day?(Required)

5mg

10mg

20mg

Hidden

1Were you happy with your treatment with Tadalafil (Cialis or generic) that you took every day?

Yes, I would attempt this medication again at the same dose

Yes, but I would like to try a higher dose

Yes, but I would like to try a lower dose

No, I would prefer to try another medication

Were you happy with your treatment with Tadalafil (Cialis or generic) that you took every day?(Required)

Yes, I would attempt this medication again at the same dose

Yes, but I would like to try a higher dose

Yes, but I would like to try a lower dose

No, I would prefer to try another medication

Why were you not happy with your treatment with Tadalafil (Cialis or generic) that you took every day?(Required)

It didn't work

I had side effects

Both

Were your side effects intolerable?(Required)

Yes

Please tell us more about the side effects you experienced.(Required)

Hidden

What is the highest dose of Tadalafil (Cialis or generic) that you used only before sexual activity?

5mg

10mg

15mg

20mg

What is the highest dose of Tadalafil (Cialis or generic) that you used only before sexual activity(Required)

5mg

10mg

20mg

Hidden

1Were you happy with your treatment with Tadalafil (Cialis or generic) that you used only before sexual activity

Yes, I would attempt this medication again at the same dose

Yes, but I would like to try a higher dose

Yes, but I would like to try a lower dose

No, I would prefer to try another medication

Were you happy with your treatment with Tadalafil (Cialis or generic) that you used only before sexual activity(Required)

Yes, I would attempt this medication again at the same dose

Yes, but I would like to try a higher dose

Yes, but I would like to try a lower dose

No, I would prefer to try another medication

Why were you not happy with your treatment with Tadalafil (Cialis or generic) that you used only before sexual activity?(Required)

It didn't work

I had side effects

Both

Were your side effects intolerable?(Required)

Yes

Please tell us more about the side effects you experienced.(Required)

Hidden

According to your answer, you might qualify for:

Tadalafil (Cialis)

Sildenafil (Viagra)

According to your answer, you might qualify for:

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