You’re about to begin a 100% online medical intake to see if you can be prescribed YouthFuel meds by a medical professional. Would you like to continue?

Please note the following responses will be used by a physician to help determine if you are eligible for treatment. Please make sure to answer each question accurately. By continuing you agree to communication with a physician if further clarification or questions are required.

Yes, I will answer each question honestly and accurately

Nope, let’s not continue

How long have you been experiencing issues with hardness, strength of erection or ability to obtain/maintain an erection?

How concerned are you with your erectile dysfunction symptoms?

I’m very concerned

I’m fairly concerned

Not concerned at all

Have you ever been treated with medication for ED?

Yes

No, this would be my first time

Do you have any allergies or medication reactions?

Yes

Have you experienced any of the following symptoms in the last 6 months?

Chest pain when climbing 2 flights of stairs or walking 4 blocks

Chest pain with sexual activity

Severe lightheadedness, fainting or near fainting

None of these

Explain the symptoms you've experienced in as much detail as you can.

What medications do you take?

Please include both prescription and over-the-counter medications you take regularly. Some medications are dangerous to take with ED medications.

Please provide the specific name of each medication you take.

Example: Lisinopril 10 mg once per day for blood pressure.

Type ‘none’ if this does not apply."

Have you had a medical evaluation which included your vitals being tested, within the past 2 years? Vitals include weight, blood pressure, and heart rate.

Yes

Within the past 12 months, how has your blood pressure been?

If you have high blood pressure is it being treated by a medical professional?

I do not have high blood pressure

Yes, it is being treated by a medical professional

It is not being treated (but I do have high blood pressure)

Are you currently prescribed any ‘nitrate’ medication(s)?

Yes

Which 'nitrate' medication(s)?

ED meds and recreational drugs don’t mix. Please let us know if you take any of these. Do you currently or have you within the past 6 months, smoked or used any of the following recreational drugs?

All responses are 100% confidential

Is there anything else you would like your doctor to know?

I agree to terms & conditions provided by YouthFuel. By providing my phone number, I agree to receive text messages from YouthFuel.