Just answer the questions below. You can bring the responses to your next doctor
appointment. It's a great way to start the conversation. It will also help your
doctor assess your situation.
To find out if VIAGRA is right for you, answer a few questions about your health. Then bring the responses to your next doctor appointment. It's also a great way to start the conversation. It will help your doctor assess your situation.
Your information is not stored or shared with anyone.
What your doctor needs to know
1. How often do you have difficulty getting or maintaining an erection?
__75% of the time or more
__50% of the time
__25% of the time
__Once in a while
__I do not have any difficulty
2. What other medical conditions do you have? (select all that apply)
__High cholesterol
__High blood pressure
__Diabetes
__Other
__I do not have any other medical conditions
3. Have you recently had surgery?
__Yes __________________(name of surgery)
__No
4. What types of medicine are you currently taking? (select all that apply)
__Herbal medicine
__Over-the-counter medicine
__Prescription medicine
__I do not take any medicine
5. Do you drink or smoke?
__No
__I only drink
__I only smoke
__I drink and smoke
Print this page and share your responses with your doctor.
__75% of the time or more
__50% of the time
__25% of the time
__Once in a while
__I do not have any difficulty
2. What other medical conditions do you have? (select all that apply)
__High cholesterol
__High blood pressure
__Diabetes
__Other
__I do not have any other medical conditions
3. Have you recently had surgery?
__Yes __________________(name of surgery)
__No
4. What types of medicine are you currently taking? (select all that apply)
__Herbal medicine
__Over-the-counter medicine
__Prescription medicine
__I do not take any medicine
5. Do you drink or smoke?
__No
__I only drink
__I only smoke
__I drink and smoke
Print this page and share your responses with your doctor.
1. How often do you have difficulty getting or maintaining an erection?
__75% of the time or more
__50% of the time
__25% of the time
__Once in a while
__I do not have any difficulty
2. What other medical conditions do you have? (select all that apply)
__High cholesterol
__High blood pressure
__Diabetes
__Other
__I do not have any other medical conditions
3. Have you recently had surgery?
__Yes __________________(name of surgery)
__No
4. What types of medicine are you currently taking? (select all that apply)
__Herbal medicine
__Over-the-counter medicine
__Prescription medicine
__I do not take any medicine
5. Do you drink or smoke?
__No
__I only drink
__I only smoke
__I drink and smoke
Print this page and share your responses with your doctor.
__75% of the time or more
__50% of the time
__25% of the time
__Once in a while
__I do not have any difficulty
2. What other medical conditions do you have? (select all that apply)
__High cholesterol
__High blood pressure
__Diabetes
__Other
__I do not have any other medical conditions
3. Have you recently had surgery?
__Yes __________________(name of surgery)
__No
4. What types of medicine are you currently taking? (select all that apply)
__Herbal medicine
__Over-the-counter medicine
__Prescription medicine
__I do not take any medicine
5. Do you drink or smoke?
__No
__I only drink
__I only smoke
__I drink and smoke
Print this page and share your responses with your doctor.
