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Weight Lbs |
Height Inches
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Do you have any known drug allergies?
If yes, please list in the box provided:
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Do you use tobacco products?
If yes, please quantify type of product and usage:
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Do you consume alcohol?
If yes, please quantify type of product and usage:
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Do you currently follow a routine exercise program?
If yes, please quantify type and amount of exercise:
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Viagraź is contraindicated in individuals who are currently taking or have a history of taking any 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.
If you cannot take this medication you should check our herbal partner at
http://ichiban-herbal-store.com.
Are you taking any of the following? |
| Dilarate-Sr Nitrek (transdermal) |
Nitrostat |
| Erythatyl Tetranitrate |
Nitro-Bid |
| Nitrolingal Spray |
Imdur |
| Nitro-Time |
Nitro-Par |
| Ismo |
Nitrong |
| Nitrodisc |
Isordil |
| Nitro-Dur |
Nitrol Ointment |
| Isosorbide Dinitrate |
Nitrogard |
| Transderm-Nitro |
Sorbitrate |
| Isosorbide Mononitrate |
Monoket Nitroglyn |
| Pentaerythritol Tetranitrate |
Nitroglycerin |
| Sodium Nitroprusside |
Itraconazole |
| Erythromycin |
Cimetidine |
| Ketoconazole |
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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:
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Are you currently taking any medications that have nitro or isosorbide in their names?
If yes, please list:
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Are you currently taking any other prescription and/or over the counter medication?
If yes, please explain: For Example: Atenolol 50mg one per day - 5 year history of hypertension (high blood pressure) well controlled with medications, Blood pressure 132/84.
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Do you have any of the following medical conditions?
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| Diabetes |
Pyronie's Disease |
| Thyroid Disease |
Multiple Myeloma |
| Leukemia |
Claudication |
| Sickle Cell Anemia |
Spinal Cord Injury |
| Schizophrenia |
Benign Prostatic Hypertrophy |
| Kidney Disease |
Prostatic Cancer |
| Liver Disease |
Valvular Heart Disease |
| Hepatitis |
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Do you have any of the above medical conditions?
If yes, please explain:
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Have you suffered a myocardial infarction, stroke or life threatening arrhythmia within the last 6 years?
If yes, please explain:
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Do you have a resting hypotension (low blood pressure) or hypertension (high blood pressure)? Normal BP is 120/80?
If yes, please explain:
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Do you have congestive heart failure or coronary artery disease causing unstable angina (chest pain)?
If yes, please explain:
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Do you have Retinitis Pigmentosis?(a minority of these patients have genetic disorders of retinal phosphodiesterase)
If yes, please explain:
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Do you have a history of any other medical condition?
If yes, explain:
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Have you had any surgeries in the past five (5) years?
If yes, please explain:
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The following questions are somewhat personal, however, this is the same information that would be requested if you were to visit a clinic with physicians who specialize in erectile dysfunctions. |
Viagraź is prescribed for the treatment of erectile dysfunction. Generally, our physicians will only prescribe the medication to individuals that have some difficulty in this area. Do you have difficulties achieving and/or maintaining an erection sufficient for sexual intercourse?
If yes, please explain:
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Have you ever been evaluated and subsequently treated for erectile dysfunction?
If yes, please explain (injection therapy, vacuum pump, penile implant, etc.):
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Your approved Viagraź prescription entitles you to your original order plus three (3) additional refills at this time or over the next twelve (12) months. Please check a box below to indicate your order.
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