Online ED Medication Request Please Select Your Nearest OMC LocationBendEugeneDo you have any of the following medical problems?High blood pressureYesNoPulmonary HypertensionYesNoType 2 diabetesYesNoType 1 diabetesYesNoHistory of heart attack or heart failureYesNoYou 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 arteriesYesNoYou 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 circulationYesNoYou 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 pressureYesNoYou 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 syncopeYesNoYou 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 diseaseYesNoSurgery or radiation to the prostate glandYesNoNeurological disease like MS or spinal cord traumaYesNoYou 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 rhythmsYesNoYou 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 murmursYesNoYou 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 cholesterolYesNoHistory of organ transpant (kidney, liver, heart, etc)YesNoYou 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)YesNoIf 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 exerciseYesNoYou 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 activityYesNoYou 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)YesNoYou 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 beatsYesNoYou 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.YesNoYou 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.)YesNoYou 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. ErythromycinYesNoCocaineYesNoYou 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. MethamphetaminesYesNoYou 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. ClarithromycinYesNoKetoconazoleYesNoRitonavirYesNoCimetidineYesNoRifampinYesNoalpha-blockers (doxazosin, terazosin, hydralazine)YesNoYou 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 NitrateYesNoYou 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 RushYesNoYou 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)YesNoYou 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)YesNoYou 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?YesNoIf yes, which ones? Sildenafil (Viagra, Revatio) Tadalafil (Cialis) Vardenafil (Levitra, Staxyn) Avanafil (Stendra) OtherIf you selected "Other" above, please list them below:Did you experience any side effects?YesNoIf yes, then what where they?How often to you anticipate using medication for ED?DailyWeeklyMonthlyOtherIf you selected "Other" above, please elaborate below:ADAM QuestionnaireDo you have a decrease in libido (sex drive)?YesNoDo you have a lack of energy?YesNoDo you have a decrease in strength and/or endurance?YesNoHave you lost height?YesNoHave you noticed a decreased "enjoyment of life”?YesNoAre you sad and/or grumpy?YesNoAre your erections less strong?YesNoHave you noticed a recent deterioration in your ability to play sports?YesNoAre you falling asleep after dinner?YesNoHas there been a recent deterioration in your work performance?YesNoIf 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?YesNoGiven that you have, or suspect you have, low testosterone, please schedule an appointment with us.Schedule an AppointmentYou are a Candidate for ED MedicationWhich Medication Would You Like to Order?10 Tablets of Tadalafil (Generic Cialis): $15010 Tablets ot Sildenafil (Generic Viagra): $100Your 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 NameEmail AddressPhone NumberIs there anything else OMC needs to know about your health?
