Online ED Medication Request Online ED Medication Request Please Select Your Nearest OMC Location Bend Eugene Do you have any of the following medical problems?High blood pressure Yes No Pulmonary Hypertension Yes No Type 2 diabetes Yes No Type 1 diabetes Yes No History of heart attack or heart failure Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Hardening of the arteries Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Poor blood circulation Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Severe low blood pressure Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. History of syncope Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. History of liver disease Yes No Surgery or radiation to the prostate gland Yes No Neurological disease like MS or spinal cord trauma Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Abnormal heart rhythms Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Acquired or congenital heart defects, valve problems or murmurs Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. High cholesterol Yes No History of organ transpant (kidney, liver, heart, etc) Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. If you have any other medical problems, please list them below.Do you have any Drug Allergies? (yes/no) Yes No If yes, which drugs? What was the last blood pressure recorded in your doctors office?Systolic:Diastolic:Do you ever experience any of the following symptoms?Chest pain either at rest or with exercise Yes No You have medical history that automatically disqualifies you from being a candidate for ED medication. If desired, please contact our office today to schedule an appointment. Schedule an AppointmentShortness of breath with minimal activity Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Pain or cramping in the legs with exercise (claudication) Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Palpitations or irregular heart beats Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Unexplained light-headedness or passing out. Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Do you use any of the following drugs or medications?Nitrates (isosorbide dinitrate, nitroglycerine, BiDil, etc.) Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Erythromycin Yes No Cocaine Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Methamphetamines Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Clarithromycin Yes No Ketoconazole Yes No Ritonavir Yes No Cimetidine Yes No Rifampin Yes No alpha-blockers (doxazosin, terazosin, hydralazine) Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Amyl Nitrate or Butly Nitrate Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Poppers or Rush Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Molly (MDMA, ecstacy) Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Adempas (Riociquat) Yes No You have a medical condition that requires an in-person visit with a physician to determine if the use of ED medications is safe for you. Please click here to schedule an appointment at OMC or discuss this with your primary care physician. Have you used any ED medications in the past? Yes No If yes, which ones? Sildenafil (Viagra, Revatio) Tadalafil (Cialis) Vardenafil (Levitra, Staxyn) Avanafil (Stendra) Other If you selected "Other" above, please list them below: Did you experience any side effects? Yes No If yes, then what where they? How often to you anticipate using medication for ED? Daily Weekly Monthly Other If you selected "Other" above, please elaborate below: ADAM QuestionnaireDo you have a decrease in libido (sex drive)? Yes No Do you have a lack of energy? Yes No Do you have a decrease in strength and/or endurance? Yes No Have you lost height? Yes No Have you noticed a decreased "enjoyment of life”? Yes No Are you sad and/or grumpy? Yes No Are your erections less strong? Yes No Have you noticed a recent deterioration in your ability to play sports? Yes No Are you falling asleep after dinner? Yes No Has there been a recent deterioration in your work performance? Yes No If you answered Yes to 3 or more ADAM Questions, please schedule an appointment for a free T-Screening at OMC. Schedule an AppointmentDo you have or suspect you have low testosterone? Yes No Given that you have, or suspect you have, low testosterone, please schedule an appointment with us. Schedule an AppointmentYou are a Candidate for ED Medication Which Medication Would You Like to Order? 10 Tablets of Tadalafil (Generic Cialis): $150 10 Tablets of Sildenafil (Generic Viagra): $100 Your Total is $150 Please fill out your information below and visit our Bend office to pay for and pick up your medication. Your Total is $150 Please fill out your information below and visit our Eugene office to pay for and pick up your medication. Your Total is $100 Please fill out your information below and visit our Bend office to pay for and pick up your medication. Your Total is $100 Please fill out your information below and visit our Eugene office to pay for and pick up your medication. Full Name Email Address Phone Number Is there anything else OMC needs to know about your health? Δ
