Home Page
Our Core Programs
Our Core Services
- Iron Infusion

Erectile Dysfunction (ED) Assessment Form

Please complete the following form accurately. Your information will help our healthcare team provide you with the safest and most effective treatment plan.

Contact Us

What is your biological sex (assigned sex at birth)?

Do you have any known drug allergies?

Yes

Do you drink Alcohol?

Do you smoke?

Yes, less than 1 pack per day

Yes, more than 1 pack per day

Do you use any of the following drugs? (Select all the applies)

Cocaine

Poppers

MDMA

Cannabis

Do you take any of the following medications?

Nitrates (e.g., nitroglycerin, isosorbide dinitrate):

Alpha-blockers (e.g., doxazosin, tamsulosin):

Option 3

HIV Protease Inhibitors (e.g., ritonavir, atazanavir):

Blood Pressure Medications (especially other antihypertensives):

Grapefruit Juice:

Do you have any of the following medical conditions?

Diabetes

Hypertension (high blood pressure)

Heart disease

High cholesterol

Neurological disorders (e.g., multiple sclerosis, Parkinson's disease)

Hormonal disorders (e.g., low testosterone)

Other:

If Other

Have you taken ED meds in the past?

How often do you have sex?

Are you looking for a medication that is long-lasting (up to 36hrs) or short lasting (up to 8hrs)?

Do you prefer a brand name or generic?

Do you have any questions for the health care team?

What is your first and last name?

New Field:

What is your phone number?

What is your email address?

What is your Alberta Health ID?

Thank you for submitting your ED assessment form.

Our healthcare team will review your information carefully and contact you within 24 hours to discuss your next steps.

Oops, something went wrong!

We weren't able to submit your form right now. Please try again or contact us directly at 403-691-5600

Integrative healthcare, designed for real results. No waitlists. No barriers and expert medical care when you need it.

1632 14 Ave NW Unit 200, Calgary, AB T2N 1M7

Phone: 403-691-5600

Fax: 403-691-5601

Company

About Us

Careers

Media Inquiries

Book a consultation

Patient Portal

FAQs
Insurance & Coverage Info
Book a Consultation
Patient Portal

Erectile Dysfunction (ED) Assessment Form﻿

Contact Us

Patient Portal

Erectile Dysfunction (ED) Assessment Form