1 Before commencing please ensure that you adhere and agree to our policies and procedures by agreeing to the following.

I confirm that I am 18 years or older
I accept Apexman's website Terms and Conditions
I consent that my information be shared with a registered healthcare practitioner

2Tell us about yourself

a. Are you a Male or Female?This question is required. *

b. What's your date of birth?

c. Your first and last name

d. Your preferred email address

3 Medical Questions

Tell us about your symptoms and overall health. The doctor needs this information to determine the most appropriate treatment for you. It's important that you are honest and respond as accurately as possible.

Q 1. Do you ever have a problem getting or maintaining an erection that is satisfying enough for sex?*

Q 2. How did your Erectile Dysfunction (ED) begin? Select the one that best describes your ED*

Q 3. Do you get erections in the following scenarios?*

Q 4. When masturbating, does your erection remain hard until orgasm or as long as you would like? *

Q 5. How often do you wake up with erections?*

Q 6. Which of the following best describes your desire to have sex?*

Q 7. Have your ever been formally treated for ED or tried any medicines, vitamins or supplements to treat it? (Understanding how or if you have attempted treatment for your ED in the past can be helpful to the physician)*

Q 8. Please tell us which of the following treatments have you used to treat your ED in the past? *

Q 9. Please tell us more about your past treatment. Include dosages, how long ago, etc. This information helps the doctor better understand your particular case of ED and how your body has responded to past treatments. If you have responded well to a specific medication, or poorly to another one, it may impact your recommended course of treatment.

Q 10. Have you had a physical exam with a healthcare provider in the past 3 years that included an examination of your genitals (penis, testis, and groin)?*

Q 11. Please explain what the issues were with your physical exam.

Q 12. Do you have any of these conditions? *

Q 13. Please list all of your current medicines, vitamins, and dietary supplements. Include any medicines (e.g., Lipitor, Zyrtec, ibuprofen), herbs, vitamins, or dietary supplements that you have taken in the past 2 weeks, even if you are not taking them today. Please include dose and frequency.

Q 14. Do you have any allergies? Include any allergies to food, dyes, prescription or over-the-counter medicines (e.g., antibiotics, allergy medications), herbs, vitamins, supplements, or anything else. *

Q 15. Please tell us a bit more about your allergies

Q 16. Do any of the following cardiovascular risk factors apply to you? *

Q 17. In the last 2 weeks, have you been troubled by any of the following? *

Q 18. Please tell us how often you've felt this way (e.g. feeling down, nervous, etc.) in the last 2 weeks?*

Q 19. Do you have any of the following conditions? *

Q 20. Do you have any of the following cardiovascular symptoms? ED is often an early sign of hardening of the arteries, which may cause difficulties with erections even before it affects the heart and causes heart attacks. *

Q 21. Do you have now, or have you ever had, any of the following conditions? This information helps our physicians provide both effective and safe dosages of medication, if appropriate. *

Q 22. Do you currently use, or have used in the past, any of the following medications? Death can result if ED meds are used in conjunction with other medications. Please, be accurate *

Q 23. Which of the following apply to you? Sometimes, lifestyle habits are associated with, contribute to, or worsen ED. Understanding your sleep, exercise, and other lifestyle habits can help your doctor make the most appropriate recommendations for you. *

Q 24. Have you, or are you currently using any of the following recreational drugs? Death or severe reactions may result if ED meds are used in conjunction with recreational drugs. *

Q 25. When was the last time you took these recreational drugs?

Q 26. If prescribed, how many times do you anticipate using the medication for sexual activity?*

Q 27. Do you have a drug preference?Your preference will be shared with a physician, who will use their medical judgement to determine the best treatment plan.*

Q 28. How often do you want your treatment to be delivered? You can save money by receiving a 3-month supply every 3 months. If you worried about stockpiling you can switch to on-demand at any time after your first order by emailing us.*

Q 29. Address, City and Postal Code of where package must be delivered

Q 30. Contact number we can call if we run into any issues with delivery

Q 31. Upload a copy of your ID or if you're going to email us a copy, press enter on your keyboard to close off the form.

Your first step to a healthier you.. Well done!

Survey Done!

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