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Medical Questionaire

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The following medical history will assist our staff physicians in deciding whether Viagra® is appropriate for your condition. All information provided will remain secure, confidential and subject to all patient/physician privilege laws. Please take a few minutes to fill in the following information as thoroughly and accurately as possible. Please note there will be a $75.00 consultation fee if the physician determines that Viagra® is appropriate for your condition. Remember that your approved Viagra® prescription entitles you to your original order plus three (3) additional refill orders over the next six (6) months

There will be NO consultation fee if the physician determines that Viagra® is not appropriate for your condition.

Personal Information Please fill in all fields. Failure to do so will delay your order processing. Items marked with an asterisk* must be completed to submit form.

First Name*

Middle Initial Last Name* Street Address* Apt City* State* Zip* Country/Province*

Phone* E-mail

Date Of Birth* (mm/dd/yy)

Sex* Height (inches)* Weight* Do you have any known drug allergies? If yes, please list in the box provided: Do you use tobacco products? If yes, please quantify type of product and usage: Do you consume alcohol? If yes, please quantify type of product and usage: Do you currently follow a routine excersize program? If yes, please quantify type and amount of excercise: Viagra® has an absolute contraindication, a condition for which a physician should not give a prescription, in an individual who is taking a medication which contain nitrates. The following is a partial list of medications that contain nitrates. The list is illustrative and not meant to be all-inclusive. Are you taking any of the following? Dilarate-Sr Nitrek (transdermal) Nitrostat Erythatyl Tetranitrate Nitro-Bid Nitrolingal Spray Imdur Nitro-Time Nitro-Par Ismo Nitrodisc Nitrong Isordil Nitro-Dur Nitrol Ointment Isosorbide Dinitrate Nitrogard Sodium Nitroprusside Transderm-Nitro Isosorbide Mononitrate Nitroglycerin Sorbitrate Monoket Nitroglyn Pentaerythritol Tetranitrate Are you currently taking any of the above medications or any other medication that contains nitrates? If you answered yes, please list in the space provided here: Are you currently taking any medications that have nitro or isosorbide in their names? If yes, please list: Are you currently taking any of the following medications? Itraconazole Cimetidine Erythromycin Ketoconazole Are you currently taking any other prescription and/or over the counter medication? If yes, please list: Do you have any of the following medical conditions? Diabetes Thyroid Disease Leukemia Pyronie's Disease Multiple Myeloma Claudication Sickle Cell Anemia Spinal Cord Injury Schizophrenia Benign Prostatic Hypertrophy Kidney Disease Prostatic Cancer Liver Disease Valvular Heart Disease Hepatitis

Medical Definitions

Do you have any of the above medical conditions? If yes, please explain:

The FDA has issued new patient warnings regarding the use of Viagra® in patients with any of the following; specifically,

Have you suffered a myocardial infarction, stroke or life threatening arrhythmia within the last 6 years? Do you have a resting hypotension (BP less than 90/50) or hypertension (BP greater than 170/110)? Normal BP is 120/80 Do you have congestive heart failure or coronary artery disease causing unstable angina (chest pain)? Do you have Retinitis Pigmentosis? (a minority of these patients have genetic disorders of retinal phosphodiesterase)

If you answered yes to any of the above four questions, please explain in the space provided: Do you have a history of any other medical condition? If yes, please explain: Have you had any surgeries in the past five (5) years? If yes please explain: The following questions are somewhat personnel, however, this is the same information that would be requested if you were to visit a clinic with physicians who specialize in erectile dysfunctions. Viagra® is prescribed for the treatment of erectile dysfunction. Do you have difficulties achieving and/or maintaining an erection sufficient for sexual intercourse? If yes, please explain: Have you ever been evaluated and subsequently treated for erectile dysfuntion? If you answered yes, please explain (injuction therapy, vacuum pump, penile implant, etc.):

You have completed the Medical Questionaire!

By submitting this consultation form:

I certify that I am 18 years of age or older.

I have read and agree to the Waiver of Liability.

I am legally allowed to receive prescription medication at my shipping address.

I understand all the side effects of Viagra®.

I do not have a current prescription for Viagra® from another physician.

I certify that I am allowed by law to use the credit card I have presented.

I understand that my credit card will be billed $75.00 for this consultation, along with my Viagra® pill order.

I understand that falsifying information in order to obtain prescription medication is a violation of both state and federal law. I hereby certify that I have answered all questions truthfully.

Hit this submit button and your questionaire will be sent via our secure server to our staff physicians. You will then be linked directly to our Online Viagra® shopping cart system.

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