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ED Alpha questionnaire survey

Have you ever received treatment for ED? Including prescription medications, over the counter medications, or any other treatment.

Cialis
Viagra
Levitra
Other (supplements, herbs, pumps, penile implants, penile injections, or other over-the-counter products?)
No, I have never been treated for ED

What dosage of Viagra?

1 - 5 mg
6 - 10 mg
11 - 15 mg
16 - 20+ mg

What dosage of Cialis?

1 - 5 mg
6 - 10 mg
11 - 15 mg
16 - 20+ mg

What dosage of Levitra?

1 - 5 mg
6 - 10 mg
11 - 15 mg
16 - 20+ mg

Did you experience any side effects that required you to stop treatment?

Yes
No, I did not experience any side effects
No, I did not stop the treatment after experiencing side effects

What side effects did you experience?

Please explain the other treatment.

Do you ever have issues sustaining an erection long enough for sex?

Yes, sometimes
Yes, most of the time
Yes, every time
No, I never have issues getting or maintaining an erection

Are you or have you previously been diagnosed with pulmonary hypertension?

What medications have you been prescribed for this?

Are you or have you previously been diagnosed with benign prostate hyperplasia?

What medications have you been prescribed for this?

Have you ever had issues initiating or stopping urinary flow?

Sorry.

Based on your answers, we won't be able to provide you with telemedicine services at this time. If you have any questions or comments please email them to [email protected] and we will get back to you as soon as possible!

How has your ED developed over time? Select the answer that best describes your experience.

Gradually, worsening over time
Suddenly, with the same partner
Suddenly, with a new partner
I don’t remember

In what situation will you get an erection?

When masturbating
When you wake up

While masturbating, are you able to maintain your erection until orgasm?

No
Yes, but rarely
Yes, sometimes
Yes, most of the time
Yes, every time

How often do you wake up with an erection?

Every time
Rarely
Sometimes

In the past five years, have you received a physical exam (which included examining your groin, penis and testis) from a healthcare provider? If not, please visit your healthcare provider before continuing with Alpha’s services.

Yes, my results were normal
Yes, but there were issues
No

Please describe the issues found in your last physical exam:

In order to receive treatment, you will need to provide your blood pressure reading taken within the last six months. It’s important that you provide this information accurately to avoid potential health risks associated with ED medication. This information will determine whether ED medication is safe for you to use.

Continue, I know my blood pressure
I do not know my blood pressure

No problem. Enter your email address and we will send you the closet place to get your blood pressure reading for free.

In the last 6 months, what was the top number of your blood pressure reading? Your blood pressure result will always be stated as a higher number over a lower number, we’re looking for the higher number here.

95-120
120-139
140–159
160 or higher
Less than 95

In the last 6 months, what was the bottom number of your blood pressure reading? Your blood pressure result will always be stated as a higher number over a lower number, we’re looking for the lower number here.

Less than 65
65–80
80–90
90–100
Over 100

Please confirm that this is your blood pressure reading, taken within the last six months.

/ mmHg

Yes, that is correct
No, I need to re-enter my blood pressure reading

How would you describe your sex drive, or desire to have sex? Choose the answer that best describes you.

Unchanged
I am less interested in sex than I was
I am less interested in sex because I know I have trouble getting and maintaining an erection
I became less interested in sex before having trouble with erections
I have less interest in sex and trouble getting erections, but don’t know which came first.

Which, if any, of the following conditions apply to you? Please select any and all that you have currently, or have had previously.

I have been advised not to have sex by my health care provider

Severe low blood pressure

A clotting or bleeding disorder

HIV

A heart attack, heart failure, or narrowing of the arteries

Idiopathic hypertrophic subaortic stenosis

Sickle cell anemia, myeloma, or leukemia

Retinitis pigmentosa or anterior ischemic optic neuropath

A history of Qt prolongation (including in your family)

Stroke or severe insufficiency of the autonomic nervous system

You’ve previously answered that you have HIV, can you please tell us more? Do you know your CD4 count? What was your last viral load and when was it measured? Are you currently taking any medication for HIV? If so, what medications?

I acknowledge that these medications do not protect me from the transmission or contraction of HIV, aids, or any other sexually transmitted disease or illness.

You have previously answered that you have had a heart attack. Can you please tell us more? When did your heart attack occur? How are you currently receiving treatment?

Which, if any, of the following conditions apply to you?

Pain with erections or with ejaculation

A foreskin that is too tight

Fibrous tissue in the penis (hard lumps and bumps under the skin)

Peyronie’s disease (a marked curve or bend in the penis that interferes with sex)

Does your Peyronie’s disease prevent you from having sex? Is it painful? Have you been treated for this condition? If so, what kind of treatment? Please explain.

Please tell us more about the pain you experience when you have an erection or when you ejaculate:

Have you received treatment for this condition? If so, what kind of treatment? Does your tight foreskin cause pain when you have an erection? Does this affect your sex life? Can you pull your foreskin back and forth over the head of your penis? Please explain.

Has a physician examined the fibrous tissue in your penis? What was the diagnosis? Have you received treatment for this condition? If so, what kind of treatment did you receive?

In order to get a better understanding of what could be causing your ED, we’ll need to learn more about your lifestyle habits. Select all that apply.

I do not eat as healthily as I should

I do not exercise regularly

I smoke tobacco

I sleep fewer than 7 hours a night

I’m more than 20 pounds overweight

I drink more than 2 drinks a day

Which, if any, of the following conditions apply to you? Please select any and all that you have had or currently have.

Any acquired, congenital, or developmental abnormalities of the heart including heart murmurs

Heart arrhythmias (an abnormal beating of the heart)

Ulcers present in the stomach, bowels, and or intestinal tract

Multiple sclerosis or a similar disease, spinal injuries or paralysis, or neurological diseases

Liver disease

Surgery or radiation to the prostate or pelvis

Kidney transplant or any condition affecting the kidney

Please tell us more about your heart arrhythmia or murmur. Have you been treated for this condition? If so, what kind of treatment?

Please tell us more about your heart arrhythmias. When was this discovered? Did you ever or are you currently receiving any treatment? If so, what is the current treatment?

Please tell us more about your ulcer(s). Where was it located? Has it healed? Have you received treatment for this condition? If so, what kind of treatment?

You have previously answered that you have MS or a similar disease, spinal injuries or paralysis, or a neurological disease. Have you ever had low blood pressure? Have you ever had labile blood pressure (blood pressure that fluctuates between high and low)? Please indicate which condition applies to you and what (if any) treatment you are receiving.

Please tell us more about your liver disease. What is the diagnosis and its status? Is your condition being monitored? Please explain what treatment (if any) you are receiving.

Please tell us more about your surgery or radiation. What condition required you to receive this treatment? What was the procedure and when did it occur? Are you currently receiving treatment?

Please tell us more about your kidney transplant or condition. What was the diagnosis? Are you still receiving treatment?

Have you ever experienced any of the following symptoms?

Abnormal heart beats. (unusually slow, irregular, or unusually fast)

Chest pain or shortness of breath when walking up at least 2 flights of stairs

Unexplained fainting, dizziness or feeling lightheaded

Unexplained muscle soreness (without cause from exercise), cramping or pain in the legs

Please describe your abnormal heart beats. Have you received any treatment for this? If so, what kind?

Please describe instances in which you have fainted, felt lightheaded, or dizzy. Have you received treatment for this? If so, what kind?

Please describe the pain in your legs. Where is the pain located? What does it feel like? How intense is it? Does any activity cause the pain? If so, what kind?

Do any of the following apply to you?

Diabetes

High blood pressure

High cholesterol

My father had a heart attack or heart disease (at 55 or younger)

My mother had a heart attack or heart disease (at 65 or younger)

Do you currently take any medication for your diabetes? What is your average daily blood sugar? How long ago was your most recent HA1c and what was it?

How is your high blood pressure being treated? What medications, if any, are you taking? What is the dosage?

Do you currently take any medication for your high cholesterol? If so, what is the medication and dosage? If you know your total cholesterol, LDL, HDL, and triglycerides please list them here.

Combining ED medication with other medications can be fatal. Please select all that apply. I use or have used:

Alpha blockers (used to treat high blood pressure or prostate problems) Common medications include, Regitine or Oraverse (phentolamine), Cardura (doxazosin), Flomax (tamsulosin), Hytrin (terazosin), Minipress (prazosin), Coreg (carvedilo), Rapaflo (silodosin), Trandate (labetalol), Uraxatral (alfuzosin).

Nitroglycerin in any form (i.e. as a spray, ointment, patch or tablet)

Medicine containing nitrates

Sildenafil (Revatio), used to treat pulmonary hypertension

Isosorbide mononitrate or Isosorbide dinitrate. (Dilatrate, Dilatrate-SR, Imdur, Ismo, Isordil, Monoket, Sorbitrate)

Adempas (Riociquat), used to treat pulmonary hypertension

Are you currently taking alpha blockers? If so, what is the medication and dosage? How long have you been taking the medication? Have you had any side effects?

Please explain your use of Nitroglycerin. Please be specific, what have you used in the past? Do you continue to use this or expect to use this in the future?

Combining use of ED medication with recreational drugs can be fatal.Have you used the following drugs within the past 2 months?

Cocaine

Molly (MDMA, ecstasy)

Poppers or Rush

Amyl Nitrate or Butyl Nitrate

Other

Please describe your use of Poppers or Rush. Do you continue to use them? If so, how frequently? When was the last time?

Please describe your use of cocaine. Do you continue to use cocaine? If so, how frequently? When was the last time?

Please describe your use of Molly (MDMA, ecstasy). Do you continue to use them? If so, how frequently? When was the last time?

Please describe your use of Amyl Nitrate or Butyl Nitrate. Do you continue to use them? If so, how frequently? When was the last time?

Please list and describe any other recreational drugs you have used or currently use.

Do you take any other medicines? Including, antifungals, medications for your prostate, erythromycin, or over the counter medicines, such as allergy medications, pain relievers, herbs, supplements or vitamins?

Please list the other medications you take and their doses here.

Do you have any allergies? Including to food, medication, dyes or anything else.

Please list your allergies below.

In the past 3-4 weeks, have you experienced any of the following?

Feeling hopeless or depressed

Lack of interest or pleasure in activities

Feeling anxious, nervous or on edge to the point it affects your daily life. (i.e. making you unable to function at work or at home)

Intense feelings of worry, to the point that if affects your daily life. (i.e. making you unable to function at work or home)

How long have you been feeling this way?

Every day
Most days
Only some days

If there something else you think we should know?

Is there anything else you would like the doctor to know?

Do you have any questions for the pharmacist?

Pharmacist questions?

Attach picture of your driver license

A picture of driver license

If prescribed, which pharmacy would you like to fulfill your treatment?

Alpha’s preferred pharmacy

Free shipping
Discreet packaging
Best pricing

I certify everything I have said is accurate

Choose a different pharmacy

Pharmacy Name: Address: City: State: Zip code: I certify everything I have said is accurate

Thanks!

Are you sure you want to use a different pharmacy?

The best prices and free delivery are only guaranteed through Alpha’s pharmacy. Receiving your prescription may take an additional 2-3 days when using another pharmacy.

NO, I’LL USE A DIFFERENT PHARMACY

You must submit a completed questionnaire to receive your Alpha order.

INFORMED CONSENT REGARDING USE OF TELEMEDICINE SERVICES

Patient’s Legal Name
Location	,
Date of birth	1970-01-01
Date of consent	01/20/2020
Telemedicine Services Provider	Foster Medical - (859)-300-6006

PURPOSE

Welcome to Alpha MD! Your health is important to us. Please carefully review the information below. This document is intended to inform you of the risks associated with telemedicine services. Your understanding of Telemedicine is important before any services can be provided to you.

WHAT IS TELEMEDICINE?

Telemedicine is a method for providing efficient medical care services using an interactive telecommunications system (e.g. the Internet or telephone) by a physician or practitioner who is licensed under state law to provide medical services to a patient in a location other than the location of the licensed medical practitioner (“Telemedicine Services”). Telemedicine Services use digital and electronic communications to enable a patient to share medical information with a health care provider in order to allow him or her to consult with, evaluate, diagnose, or treat the patient. The delivery of telemedicine healthcare allows the patient and health care provider to establish a relationship from anywhere, independent of their location. In order to use the Telemedicine Services, you must have and maintain access to an interactive telecommunications system.

BENEFITS

Telemedicine Services provide improved access to medical services and care. This includes the expertise of specialists who may not be available for a face-to-face consultation. Telemedicine Services can also provide efficient care in evaluations, medical consultations, diagnoses, and treatment, leading to improved access to medical care.

POTENTIAL RISKS

Telemedicine Services offer an efficient way for medical care providers and patients to communicate and there are few risks associated with the use of Telemedicine Services. Potential risks include:

Delayed medical evaluation and treatment due to telecommunication equipment failures or information transmission errors (e.g. poor image quality);
The possibility that the transmission of your medical information could be disrupted or distorted by technical failures;
Risks related to a patient withholding key medical information or records, which may result in adverse or allergic reactions to prescribed drugs, and other complications; or
Unauthorized access of protected health information (PHI) as a result of cyber security or other security breaches.

Do I have to use Telemedicine?

Use of Telemedicine Services is voluntary and not required. You may always seek traditional, face-to-face medical care (e.g., face-to-face consultations with, or examinations by, a medical care provider).

INDEMNIFICATION

YOUR USE OF THE TELEMEDICINE SERVICES IS VOLUNTARY. YOU AGREE TO INDEMNIFY AND HOLD HARMLESS ALPHA MD, LLC, THE TELEMEDICINE SERVICES PROVIDER, AND THEIR RESPECTIVE MEMBERS, MANAGERS, REPRESENTATIVES, DIRECTORS, AGENTS, EMPLOYEES, PARENTS, SHAREHOLDERS, PREDECESSORS, OFFICERS, AND SUCCESSORS FROM AND AGAINST ANY AND ALL LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIMS, OR DEMANDS BROUGHT BY ANY PARTY WHATSOEVER, ARISING OUT OF OR RELATED TO ANY FAILURE OF TECHNOLOGY OR EQUIPMENT IN CONNECTION WITH THE PROVISION OF TELEMEDICINE SERVICES WHETHER OR NOT ANY SUCH LOSS, DAMAGE, EXPENSE, LIABILITY, CLAIM, OR DEMAND ARISES FROM OR RELATES TO ALPHA MD, LLC’s OR THE TELEMEDICINE SERVICES PROVIDER’S NEGLIGENCE.

FOLLOW-UP CARE; EMERGENCY SITUATIONS

If you are experiencing a medical emergency, call 911 or seek care at an emergency room facility or other provider equipped to deliver urgent care.

If there is an urgent situation in which you experience an adverse reaction, or technical difficulties prevent you from communicating with the Telemedicine Services Provider, or if you no longer wish to use Telemedicine Services, stop using the Telemedicine Services and please contact the Telemedicine Services Provider at the number listed above.

YOUR PRIVACY RIGHTS

We protect your patient information using industry standard network and software security protocols designed to safeguard the data you provide us. Your medical record, imaging, and personal financial data are all kept confidential using these protocols. Except as permitted by applicable law and as set forth in , your personal information, including your health information, will not be shared or disclosed to any third party without your consent.

By signing this form, I acknowledge that I have read and understand the risks and benefits of participating in Telemedicine Services and I have received answers to all of my questions to my satisfaction. I further acknowledge and understand that:

I will need to provide my full and accurate medical history, including any pre-existing medical conditions, so that my provider can access and determine a treatment plan for me.
My provider will determine whether Telemedicine is appropriate for me based on my diagnosed condition.
My results cannot be guaranteed and I may or may not benefit from health services provided by Telemedicine.
I will be informed by the Telemedicine Services Provider whether any other persons are present at the provider’s location during the Telemedicine service and I have the right to choose who may or may not be present.
I have the right to object to any Telemedicine service without prejudice to any care or treatment that may take place in the future, and without risk of losing any health benefits to which I may be entitled.
I will be informed of any charges associated with my Telemedicine Services prior to incurring any charges, and agree that I am responsible for paying the full amount of all costs associated with my Telemedicine Services, including any prescriptions I receive.
I may not submit a claim to Medicare, any other federal payor, or any state or private insurer regarding any fees for the Telemedicine Services.
Telemedicine is subject to laws that protect my privacy and maintain the confidentiality of my medical information.
The Telemedicine Services Provider may provide my confidential health information to outside medical providers, potentially in other locations, as necessary.
I have the right to view and obtain copies of all information exchanged during any Telemedicine session, concerning the policies of the physicians, assistants, nurse practitioners and facilities involved in my care.
I may be charged a fee to receive copies of my records in accordance with applicable state regulations.
All photos appearing on this site are models and not actual patients unless otherwise stated.

If you have a concern about a medical professional, you may contact the Medical Board regarding your concerns:
Kentucky Medical Board:
310 Whittington Parkway Suite 1B Louisville, KY 40222 Phone: (502) 429-7150 Fax: (502) 429-7158

By clicking "I Agree" below, I understand and agree to the foregoing acknowledgements and disclosures including Telemedicine Services Provider’s Terms of Service and Notice of Privacy Practices. I further understand that Alpha MD, LLC has a commercial and financial relationship with Telemedicine Services Provider; that I am free at any time to obtain a medical examination and advice from another healthcare provider that is not associated with Alpha MD, LLC; that I am free to obtain my prescription from any pharmacy of my choice; and that if I wish, Alpha MD, LLC will use its partner pharmacy to fulfill my prescription order(s), if any, as a convenience to me. BY CLICKING "I Agree" I CONSENT AND PROVIDE MY ELECTRONIC SIGNATURE.

I agree

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