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Medical History

Patient Info

Please fill out the medical history form below. For new patients, the medical history form is required to be submitted before your order can ship out.

Please enter the date
Please enter your name (last first middle).
Please enter your birthdate
Please enter your occupation
Please enter your email address.
Please enter your Referring Physician Name.
Please enter your Referring Physician Specialty.
Please enter your Primary Care Physician Name.

Patient history

Please enter your age.
Please enter Approximate Duration of problem in years.
Present Sexual Function:
Previous Evaluation:
Previous Treatment:
Risk Factors For Erectile Dysfunction:
Past Medical History:

Family History:
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