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Medical History:explanations if your answer is "yes" to any of the following.
Please read the following list of medical conditions carefully. Be sure to give any
Do you or any of your immediate family have a history of the following medical conditions? 
Blood disorders e.g. anemia, hemophilia, hemochromatosis, phlebitis, sickle cell anemia, thalassemia, thrombosis, hypercholesterolemia, etc.
  
Cancer e.g. brain, breast, bladder, colorectal, endometrial, leukemia, lung, lymphoma, multiple myeloma, ovarian, prostate, skin, testicular, etc.
  
Cardiovascular disease e.g. angina, arrhythmia, atrial fibrillation, claudication, congestive heart failure, valve disorder, heart attacks, high blood pressure, strokes, etc.
 
Endocrine disorder e.g. diabetes, goiter, hyperthyroidism, hypothyroidism, pheochromocytoma, thyroiditis, etc.
  
Eye disorders e.g. cataracts, glaucoma, retinal complications, etc.
  
Gastrointestinal disorder e.g. acid reflux, hiatal hernia, irritable bowel syndrome (Crohn's disease, ulcerative colitis), polyps, rectal bleeding, ulcers, etc.
  
Genitourinary disorder e.g. benign prostatic hyperplasia, cysts, endometriosis, pelvic inflammatory disease, etc.
  
Immune disorders e.g. Hashimoto's disease, eczema, HIV, Graves disease, Sjogrens syndrome, sarcoidosis, sclerodoma, etc.
  
Kidney (urinary tract) disorder e.g. bladder disorders, cystic disease, glomerular disease, nephrotic syndrome, renal failure, urinary tract complications, etc.
  
Liver disorder e.g. cirrhosis, Gilbert's syndrome, hepatitis, hemochromatosis, Wilson's disease, etc.  
Musculoskeletal e.g. arthritis, back/spine complications, fibromyalgia, gout, lyme disease, muscular dystrophy, myasthenia gravis, osteomalacia, osteoporosis, rickets, spinal cord injury, etc.  
Neurological disorder e.g. Alzheimer's disease, epilepsy, head injuries, headaches, Huntington's disease, multiple sclerosis, seizure, etc.  
Psychological disorder e.g. anxiety, attention deficit disorder, bipolar disorder, depression, obsessive compulsive disorder, panic disorder, post traumatic stress disorder, etc.  
Respiratory disorder e.g. allergic rhinitis, asthma, chronic bronchitis, emphysema, tuberculosis etc.  
Other e.g. acne, chemical dependency, menopause, nutritional disorder, obesity, pregnant/nursing, significant trauma, etc.  
Do you have a history of any of the medical conditions previously mentioned including Blood disorders, Cancer, Cardiovascular disease, Endocrine disorder, Eye disorders, Gastrointestinal disorder, Genitourinary disorder Immune disorders, Kidney (urinary tract) disorder, Liver disorder Musculoskeletal, Neurological disorder, Psychological disorder, Respiratory disorder, Other conditions (not mentioned)?
If yes, please explain. For example, duration of illness, any surgery or treatment (ten year history of  hypertension (high blood pressure), Atenolol 50mg one per day - well controlled with medications, Blood pressure 132/84):		 Yes
No
 0000000

Additional Medical:
Please read the following list of medical questions carefully. Be sure to give any explanations if your answer is "yes" to any of the following.
Currently, are you taking any medications (this includes over-the-counter or nonprescription medication, herbal supplements, sports supplements, etc.)
If yes, please explain(medication, supplement including dosage): 		Yes
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Are you allergic to any medications, supplements or food products?
If yes, please explain (medication, supplement, and the allergic reaction experienced):
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Do you consume more than two servings of alcohol per day or use tobacco products?
If yes, please quantify type of product and usage:
Yes
No
Do you currently follow a routine exercise program?
If yes, please quantify type and amount of exercise:
Yes
No
0000000

Viagra Specific Questions:
Please read the following list of medical questions carefully. Be sure to give any explanations if your answer is "yes" to any of the following.
Do you have a history of any cardiovascular complications e.g. heart attack, congestive heart failure, unstable angina (chest pain), arrhythmia (an abnormal heartbeat rhythm) uncontrolled hypertension or hypotension, history of postural hypotension, stroke, transient ischemic attacks (TIAs), etc?
If yes please explain:
 Yes
No
Do you have a history of any blood disorders e.g. sickle cell anemia, thalassemia, bleeding disorders, etc?
If yes please explain:
 Yes
No
Viagra® is contraindicated in individuals who are currently taking or have a history of taking any medication which contain nitrates. Combining Viagra with nitrates can result in a dangerously low blood pressure that can result in a heart attack, stroke or even death. Are you currently taking any medications that contains nitrates or any medications that have nitro or isosorbide in their names?
If yes please explain.
Yes
No
Do you have an abnormal curvature of the penis (Peyronie's disease) or a history of priapism (painful/prolonged erection)?
If yes please explain.
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No
Viagra® is prescribed for the treatment of erectile dysfunction. Our physicians will only prescribe Viagra for individuals that have some difficulty in this area. Do you have difficulties either achieving and/or maintaining an erection sufficient for sexual intercourse?
If yes please explain.
Yes
No
Have you ever been evaluated and subsequently treated for erectile dysfunction (injection therapy, vacuum pump, penile implant, etc.)?
If yes please explain.
Yes
No
  0000000

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Special Instructions :
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Please Note:
Our pharmacy must use a merchant account (the service that charges your credit card for Visa, American Express, etc.) that is based in the United States. Therefore, all of our prices will be converted from Euros or Pounds to United States currency.

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