SoWal Health & Wellness - ERECTILE DYSFUNCTION

Get An Appointment

Consult with Our Experts

NameAddressPhoneDate of BirthDrug AllergiesHave you Used ED Medication Previously?YesNoName/Phone of Primary Care PhysicianDo you have issues with either obtaining or maintaining an erection that is satisfying enough for sex?Please Check any medications that you have tried previously to treat erectile dysfunctionViagraCialisLevitraStaxynStendraIntraurethral-SuppositoryPenile PumpPenile ImplantShockwave TherapyList Each treatment tried and it's effectiveness / side effectsList any medications and supplements and how you take themDo you take any of the following medicationsDo you have any medical conditions or history of surgeries?Do you have a history of the following: Check if YesHypotension (Low BP)FaintingPoorly Controlled Hypertension (Hight BP)ANGINA (Chest Pain)Heart Attack, Stroke or TIA (Mini Stroke) in the last 6 monthsirregular heat rateclaudication (leg pain with exercise)Migraines with exertionDifficulty breathing when rapidly climbing 2 flights of stairsI have NONE of the above medical issuesDo you have anxiety or depression?Have you had a genital exam in the last 5 years?Any other medical conditions that we should be made aware of?Date

Thank you! Your submission has been received!

Pay for your visit head of time.

Online ED

$49.00

Pay now

Oops! Something went wrong while submitting the form.