Patient Form - Sobe Apothecary

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Name*

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Email*

Phone*

You Must be 18+ to Continue.

Date of Birth*

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Age

What Product are you Interested in?*

Select Product and Packs will appear below

Sildenafil 20mg

Sildenafil 40mg

Tidafadil 5mg

Tidafadil 10mg

Nb480 Sildenafil

Nb480 Tadalafil

Fast-Acting Sildenafil

Fast-Acting Tadalafil

Sildenafil 20mg*

6 pack

8 pack

12 pack

Sildenafil 40mg*

6 pack

8 pack

12 pack

Tadalafil 5mg*

3 pack

10 pack

Tadalafil 10mg*

3 pack

10 pack

NB480 Sildenafil*

5 pack

10 pack

NB480 Tadalafil*

5 pack

10 pack

Fast Acting Sildenafil*

5 pack

10 pack

Fast Acting Tadalafil*

3 pack

10 pack

Total

How often do you experience ED?*

Every-time

Half the time

On occasion

Rarely

What is your expectation?*

Get hard stay hard

Increase my libido

All of the above

Pick the scenario that best describes your ED*

Difficulty achieving erections

Difficulty maintaining erections

Both

How did your ED start?*

Suddenly

Gradually happened over time

Rate the typical hardness you achieve when you masturbate (emojis)*

Penis does not enlarge

Penis is larger but not harder

Penis is hard but not hard enough for penetration

Penis is hard enough to penetrate but not completely hard

Penis is hard and fully rigid

Is your desire to have sex noticeably lower than it has been in the past?*

Yes

Do you have a lack of energy?*

Yes

Do you have a decrease in strength and or endurance?*

Yes

Are you sad and/or agitated?*

Sad

Agitated

Both

Neither

Have you ever been treated with medication for ED?*

Yes

Which of the following treatments have you used to treat your ED in the past?*

Viagra or generic

Cialis or generic

Levitra or generic

Stendra or generic

Other

If Other selected, please explain

Were you happy with the treatment?*

Yes

Why were you not happy with your treatment?*

It had side effects

It did not work

Both

Please tell us more about your usage*

What is your gender?*

We ask these questions to all our patients to provide with safe and effective care, we are inclusive to everyone.

Man

Woman

Trans man

Trans woman

Gender: Queer/Nonbinary

A gender

Questioning

Another Gender

What was your sex assigned at birth?*

Male

Female

When was your most recent in person check up?*

1-2 years ago

Within the last year

2-3 years

3+ years

What was your last blood pressure reading?*

Top number

>90

90-139

140-169

170+

I don't remember

What was your last blood pressure reading?*

Bottom Number

Less than >50

50-80

81-99

100+

I don't remember

Do you take any medications, vitamins, or supplements?*

Yes

Please list any current medicines, vitamins, or dietary supplements you take regularly, including the dosage. Include exact names of any medicines (e.g. Lipitor, Zyrtec, Ibuprofen) or any supplement taken in the past 2 weeks, even if you are not taking them daily.*

Do you have any allergies?*

Include any allergies to food, dyes, prescriptions, or over-the-counter medicines (e.g. antibiotics, allergy medications), herbs, vitamins, supplements, or anything else.

Yes

If Yes, please explain*

Have you had any surgeries or hospitalizations? Yes*

Yes

Do any of the following cardiovascular risk factors apply to you?*

Diabetes

High Cholesterol

High blood pressure

My father had a heart attack or heart disease at 55 years or younger

My mother had a heart attack or heart disease at 65 years or younger

None apply to me

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.*

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.

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.*

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

Do you currently or have you within the past 6 months, smoked or used any of the following recreational drugs?*

1Poppers or Rush (Amyl Nitrate or Butyl Nitrate)

Cocaine

Cigarettes

No I don't use any of these

Other

Your provider needs to understand more about your reported use of poppers or rush to help determine if ED treatment is safe for you.*

OK, let's continue.

When was the last time you used poppers or rush?*

Within the last month

1-3 months ago

3-6 months ago

Never

How frequently do you use poppers or rush on average?*

At least once per week

At least once per month, but less than once per week

At least once every 3 months, but less than once per month

Rarely

Your provider needs to understand more about your reported cocaine use to help determine if ED treatment is safe for you.*

OK, let's continue.

When was the last time you used cocaine?*

Within the last month

1-3 months ago

3-6 months ago

Never

How frequently do you use cocaine on average?*

At least once per week

At least once per month, but less than once per week

At least once every 3 months, but less than once per month

Rarely

Last step!

Drop a note to the provider who will treat you. Feel free to ask any questions on your mind, share more info about yourself, or just say hello.

info@everreadyproducts.com

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