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View Telehealth Consent
View Telehealth Consent By
Clicking Here
Do You Agree With The Telehealth Consent Above?
Do You Agree With The Telehealth Consent Above?
Yes
No
Authorization
By submitting this form, you authorize DiVYO Health Solutions, Inc. and/or its Affiliates, to charge your credit card or debit your bank account pursuant to your request and purchases with the company. You understand that there may be a periodic charge that will be made according to your account statement cycle, and that the amount may vary based upon your pricing tier or purchase activity.
First Name
Last Name
Date of Birth
Gender
Select Your Gender
Male
Female
Phone
Email
If You Have A Code, Enter It Here!
Do You Agree With The Credit Card Consent Above?
Do You Agree With The Credit Card Consent Above?
Yes
No
Have you had a physical exam in the last three years?
Have you had a physical exam in the last three years?
Yes
No
If yes, were there any abnormalities with the exam?
If yes, were there any abnormalities with the exam?
N/A
Yes
No
Are you able to have sex like you did when you were in your 20's?
Are you able to have sex like you did when you were in your 20's?
Yes
No
With sexual stimulation can you….
With sexual stimulation can you….
Initiate an erection
Maintain an erection
Neither initiate or maintain an erection
Are you able to maintain an erection during intercourse?
Are you able to maintain an erection during intercourse?
Yes
No
Maintain an erection
With your erection, are you...
• Strongly Dissatisfied
• Dissatisfied
• Neither satisfied nor dissatisfied
• Satisfied
• Strongly Satisfied
Have you taken any of the following as treatment for erectile dysfunction? (select all that apply)
Have you taken any of the following as treatment for erectile dysfunction? (select all that apply)
• Sildenafil (Viagra)
• Tadalafil (Cialis)
• Vardenafil (Levitra)
• Testosterone Replacement
• Injections
• Surgery or use of Pumps
Have you ever been prescribed nitrates/nitroglycerin
Have you ever been prescribed nitrates/nitroglycerin?
Yes
No
In the past several months, have you had any of the following?
In the past several months, have you had any of the following?
• Chest Pain
• Passing Out
• Dizziness/Seizure
• None of the above
Is there a family history of any of the following?
Is there a family history of any of the following? (check all that apply)
• Cardiovascular disease
• Unexplained sudden death
• None of the above
In the Last Three Months, Have You Used Any of the Following Drugs Recreationally?
In the Last Three Months, Have You Used Any of the Following Drugs Recreationally? (check all that apply)
• Cocaine
• Poppers or Rush
• Opiates/Heroin
• Methamphetamine
• Molly (MDMA)
• Other
• None
Do you exercise regularly?
Do you exercise regularly?
Yes
No
If yes, how often do you exercise?
If yes, how often do you exercise?
• Everyday
• At least 3x per week
• Weekly
• Less than once a week
Have you had elevated Blood pressure in the past 6 months?
Have you had elevated Blood pressure in the past 6 months?
Yes
No
enter your blood pressure taken within the last 2 months
Do you have any allergies?
Do you have any allergies?
Yes
No
If yes, please list allergies.
are you on any medications?
Are you on any medications?
Yes
No
If yes, please list medications.
Which of the following apply to you?
Which of the following apply to you?
• I get less than 2 hours of exercise per week
• I do not ear as healthy as I would like
• I smoke or use tobacco (e.g., chewing tobacco, snuff)
• I use other nicotine containing products (e.g., vaping)
• I drink more than 2 alcoholic drinks per day
• I get less than 7 hours of sleep per night, on average
• I’m 25+ pounds overweight
• I am frequently under a lot of stress
• None apply to me
Have you experienced any of the following conditions?
Have you experienced any of the following conditions? (check all that apply)
• Enlarged prostate
• Weight gain/management
• Sleep/Insomnia
• Hair loss
• Low Testestorone
• Blood sugar/diabetes
• Acne/Roscecia/Hyperpigmentation
• Joint Issues
• Toe Nail Fungus
• Pain Management
• None
Are You Prepared To Receive A Call From A Medical Professional After Submission Of The Intake Form?
Are You Prepared To Receive A Call From A Medical Professional After Submission Of The Intake Form?
Yes
No
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