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Online Patient Intake Form – Erectile Dysfunction (ED) Evaluation

Personal Information
Full Name*
Date of Birth*
Gender*
Phone Number*
Email Address*
State*
City*
Fill required fields
Section 2: Health & Lifestyle
How often do you have trouble achieving or maintaining an erection?*
When did you first notice symptoms of erectile dysfunction?
Are your erections less firm than they used to be?*
Do you wake up with morning erections? *
Do you experience sexual desire or libido? *
Section 3: Medical History
Do you exercise regularly?*
How many hours of sleep do you get per night? *
Do you smoke or vape? *
Do you consume alcohol?*
Do you use recreational drugs? *
Do you have or have you had any of the following? (Check all that apply)*
Rate your current stress level*
Section 3: Lifestyle & Wellness
Have you been diagnosed with or experienced any of the following? (Check all that apply)*
Please list any current medications or supplements:
Section 4: Treatment Goals
Section 4: Treatment Goals
Check all that apply
Consent & Acknowledgment
Consent & Acknowledgment*
By submitting this form, I confirm that the information provided is accurate to the best of my knowledge. I understand that this questionnaire is used to determine candidacy for NAD+ and peptide therapy and does not replace a medical diagnosis or physician consultation.
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