Electronic Medical Consultation
This information will let us know more about you
Enter accurate health information to receive appropriate treatment plan.
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Patient consent to download medical history
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Yes
No
Online Treatment Agreement
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I understand that an online medical visit can be a great option for minor medical issues and not ideal for severe or life-threatening illnesses. I understand that treatment offered on CallonDoc.com is on the basis of clinical judgment, in the absence of a complete physical examination. I agree to follow up with a doctor for in-person evaluation or seek emergency care if my symptoms worsen or do not improve in a timely manner.
Do you have any condition that may render you incompetent of making sound medical decisions?
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I am capable of making sound medical decisions
I am UNABLE to make clear and sound medical decisions
Do you have an allergy to a particular medication?
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Yes, I have a history of drug allergies
No know drug allergies
If any, list all the medicines you are allergic to
Do you have any of these conditions?
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Deformation of the penis
Heart disease
Blood disorder (leukemia or myeloma)
Diabetes
Liver or kidney diseases
Low testosterone level
Sickle cell
None of these diseases
Do you have hypertension
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My blood pressure is normal (lower than 130/90)
I have elevated blood pressure (greater than 160/100)
Do you take any of these medications?
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Nitrates. nitroglycerin. isosorbide dinitrate or mononitrate
Terazosin. Doxazosin or Tamsulosin
Alfuzosin or Silodosin
Fluconazole
None of these medications
List all the medications you take, including over-the-counter drugs. (Enter None if nonapplicable)
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ED EVALUATION - Briefly describe your ED symptoms and reason for this consultation
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Which of these medical conditions apply to you? *
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Low libido (lack of interest in sex)
Premature ejaculation
Erectile dysfunction
I drink alcohol excessively
I have problems within my relationship
I suffer from depression, anxiety, bipolar, psychosis or other psychiatric disorders
When did your symptoms start?
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Less than SIX months
6-12 months ago
Over a year ago
Symptoms started at a young age (before the age of 21)
What medications have you taken or currently taking for ED? Write N/A if none
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If applicable, briefly explain your last visit to the doctor for ED
Prescription will be sent to RxCompoundStore, 8950 SW 74th Court, Suite 101, Miami, FL 33156. Ph: 786-803-8947.
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YES, I AGREE
Treatment Warning and Precaution
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I understand that I must not take Viagra or Cialis with Nitrates, terazosin, doxazosin, tamsulosin, alfuzosin, and silodosin or fluconazole to avoid severe adverse reaction
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