START WITH

The Basics

This information helps your doctor determine if you're eligible for treatment.

Biological Sex

Male

Female

Birthdate

State

Coming Soon to your State.

Zipcode

Phone Number

LET'S TALK ABOUT YOUR HEALTH

Medical Questions

Tell your doctor about your symptoms and overall health. Your 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.

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

Yes, every time

Yes, more than half the time

Yes, on occasion

Yes, but rarely

I NEVER have a problem getting or maintaining an erection for as long as I want

How did your ED begin? Select the one that best describes your ED.

Gradually but has worsened over time

Suddenly, but not with a new partner

Suddenly, with a new partner

I do not recall how it began

Do you get erections...

When masturbating

When you wake up

Neither

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

No, it starts hard but never remains hard

Yes, but only rarely

Yes, on occasion

Yes, more than half the time

Yes, always

In the past month, how satisfied have you been with your sex life?

Not at all

A little bit

Somewhat

Quite a bit

Very

Prefer not to answer

How would you describe your sex drive over the past year?

Low

Medium

High

Have you ever been formally treated for ED or tried any medicines, vitamins, or supplements to treat it?

Understanding how or if you've attempted treatment for your ED in the past can be helpful to your doctor.

No

Yes

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

Yes, and it was normal

Yes, but there were issues

No, I haven't had a physical exam in the past 3 years

Have you had your blood pressure measured in the past 6 months?

You need to know your blood pressure (BP) within the last 6 months to be evaluated for treatment. It is an important factor in deciding whether it is safe for you to use ED medication. It is essential that you are accurate and honest about your BP. When used improperly these medications can cause serious harm, or death.

Continue, I know my blood pressure

No, I don’t know my blood pressure

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.

No

Yes

Do you have any medical conditions or a history of prior surgeries?

No

Yes

PLEASE TELL US MORE

Tell us more about your high cholesterol

Do you remember your total cholesterol, LDL, HDL, triglycerides? How is your high cholesterol currently being treated?

Please list the medicine(s) you are currently taking for your high cholesterol.

In the last 2 weeks, have you been bothered by any of the following? (Select all that apply.)

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Feeling nervous, anxious, or on edge (enough that it impairs your ability to function at work or at home)

Worrying too much about different things (enough that it impairs your ability to function at work or at home)

No, I have not been bothered by feeling down, anxious, nervous, etc. In the last 2 weeks.

Do you currently have, or have you ever experienced, any of the following? (Select all that apply.)

For health reasons, or any reason, you have been advised not to have sex

HIV

Severe low blood pressure

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

Any clotting or bleeding disorder

Stroke or severe insufficiency of the autonomic nervous system

Any history of QT prolongation in you, or even in your family

Sickle cell anemia, myeloma, or leukemia

Retinitis pigmentosa or anterior ischemic optic neuropathy

Do you have any of these conditions? (Select all that apply.)

A marked curve or bend in the penis that interferes with sex, or Peyronie’s disease

Pain with erections or with ejaculation

A foreskin that is too tight

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

No, I do not have any of these conditions

Do you currently have, or have you ever experienced, any of the following? (Select all that apply.)

Surgery or radiation to the prostate or pelvis

Kidney transplant or any condition affecting the kidney

Liver disease

Multiple sclerosis (MS) or similar disease, spinal injuries or paralysis, or neurological diseases

Stomach, intestinal, or bowel ulcers

Heart arrhythmias, which is an abnormal beating of the heart

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

No, I have never had any of these conditions

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. Select all that apply.

Abnormal heart beats –rapid, irregular, unusually slow (fewer than 60 beats/minute)

Chest pain (angina) or shortness of breath while walking up 2 flights of stairs

Any episodes of unexplained fainting, light headedness, or dizziness

Cramping or pain in the calves or thighs with exercise (claudication)

None apply to me

PLEASE TELL US MORE

Tell us more about the pain in your legs.

For example, where do you get pain and what type and intensity of activity (if any) causes the pain? What makes the pain better?

Please list all medicine(s) you are currently taking to treat the pain in your legs.

Do you currently use, or have an active prescription for, any of the following?

Please select any medication or supplement that you use, even if it’s occasional use. Select all that apply.

Absolutely any medicine containing nitrates

Any alpha blocker—they are commonly used to treat high blood pressure or prostate problems

Nitroglycerin in any form – as a spray, tablet, patch, or ointment

Supplements that boost nitric oxide

Isosorbide mononitrate or isosorbide dinitrate

Adempas (riociquat), which is used to treat pulmonary hypertension

No, I have never used any of these medications

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. Select all that apply

I get less than 2 hours of exercise per week

I do not eat as healthy as I would like

I smoke or use tobacco (e.g., chewing tobacco, snuff)

I use other nicotine containing products (e.g., vaping)

I drink more than 2 alcoholic drinks per day

I get less than 7 hours of sleep per night, on average

I’m 20+ pounds overweight

I am frequently under a lot of stress

None apply to me

ALMOST DONE

Have you used any of the following recreational drugs in the past 6 months?

Please include any prescription drugs you have taken recreationally (e.g., Adderall, Xanax, or narcotics.) Select all that apply.

Methamphetamines or amphetamines (crystal meth)

Poppers or Rush

Amyl Nitrate or Butyl Nitrate

Cocaine

Molly (MDMA, ecstasy)

Other

No, I have never used any recreational drugs

Please update the list below to include all medicines, vitamins, and supplements you’re currently taking.

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.

Add medication

BEFORE WE WRAP UP

Is there anything else you want your Ro-affiliated doctor to know about your condition or health?

No

Yes

MAKE YOUR REQUEST

Treatment Preference

If you have a preferred treatment, you can let your doctor know here. While your preference will be taken into consideration, your doctor will prescribe the treatment option best suited for you.

NUMBER OF USES

How many times do you anticipate using the medication for sexual activity, if prescribed?

Use 4 times per month

Use 6 times per month (Most Popular)

Use 8 times per month

Use 10 times per month

The Ro Pharmacy Network can ship individual single packets for each use (i.e., dose).

DRUG

Do you have a drug preference?

Sildenafil ($6 per dose)

Viagra ($34 per dose)

Cialis ($44 per dose)

No preference (Please tell my doctor that I do not have a drug preference.)

You preference will be shared with a physician, who will use their medical judgement to determine the best treatment plan.

Prices listed are from the Ro Pharmacy Network for the recommended starting dose for a healthy patient. Most prescription comes in non-childproof, single-close packaging, though you may request childproof packaging for your medications.

DOSAGE

Do you have a dosage preference for Silenafil?

* A starting dose of 60mg (typically $6.00) is the most common for members who are new to the medication. Based on the information you provide, a physician will determine if this dose (or another) is appropriate.

If you know what works for you:

If you used the medication before, and it worked without side effects, you should choose the same dose.

New to medication? Start with:

60mg (3 pills) / $6 per dose

20mg (1 pills) / $2 per dose

40mg (2 pills) / $4 per dose

80mg (4 pills) / $8 per dose

100mg (5 pills) / $10 per dose

FINAL STEP!

Identity Verification

Your doctor needs to verify your identity with a photo of your face and a photo of your government-issued ID. We need a photo of your face to confirm that the government-issued ID is yours.

Upload Your ID

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Enter your email below and we'll send you the nearest and most affordable locations in your area so you can see a healthcare provider. After, come on back and a physician will review your information and, if appropriate, write a prescription to your pharmacy of choice.

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