top of page
Questionnaire for Medication Erectile Dysfunction
Are you a male aged between 18-70? Required
Have you ever taken ANY Erectile Dysfunction medication? Required
Have you taken sildenafil or tadalafil at least twice before without any serious or negative side effects? Required
Do you consume alcohol on a regular basis ? Required
Has a doctor advised you to avoid sex or strenuous physical activity? Required
Have you had a heart attack or stroke/TIA (transient Ischemic attack) or mini stroke? Required
Do you have angina (chest pain) irregular heartbeat or palpitations (arrhythmias)? Required
Do you smoke? Required
Do you have any allergies or had any adverse reactions (hypersensitivity) to any medication? Required
Have you experienced any difficulty or labored breathing or any other discomfort such as: pain in your chest , shortness of breath or any physical activity. Required
Do you have uncontrolled high blood pressure, heart problems or low blood pressure? Required
Have you ever suffered any of the following conditions:

Please contact us if you experienced side effects from the treatment, start new medication or
develop or have a change in your medical condition.


The treatment is solely for you in your own use.


You understand the healthcare provider takes your answers in good faith and base their treatment
on decisions accordingly, and that incorrect information can be hazardous to your health.


You will read the patient information leaflet supply with your medication.


You will notify your primary care physician about your treatment from PBJ medical associates.

Thanks. Please check your email now to let you know what are the next steps.

PBJ Medical RX

​JOIN OUR MAILING LIST

Thanks for submitting!

​VISIT

7380 West Sand Lake Road

Orlando, FL 32819

​

​CONTACT US

(800) 485-7962
info@pbjmedicalrx.com

PLEASE CLICK THE LINK BELOW

Medical Discliamer - PBJ Medial Associates LLC

© 2025 PBJ Medical RX. All Rights Reserved

bottom of page