Your ED Evaluation – New Please enable JavaScript in your browser to complete this form. - Step 1 of 65Your Medical EvaluationThis evaluation is unique to you, as questions change dynamically based on your answers. This removes redundant, time-consuming questions, and focuses primarily on your medical history and symptoms that help our doctors determine the best possible treatment for you.By clicking on begin you have acknowledged that you have read and understood our Privacy Policy and Terms Of Use., and consent to the collection, use and disclosure of your personal data to Noah Health Pte Ltd. for the purposes set out in the Notice.BeginWhat is your biological sex? *MaleFemaleWe're not quite ready for you yet. Join our mailing list or keep a lookout for our updates on this site!PreviousNextName *Full name as per your NRIC or PassportFirstLastPlease state your height? (in cm) *Please state your weight? (in kg) *Date of birth *DD12345678910111213141516171819202122232425262728293031/MM123456789101112/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920PreviousNextHas it been hard to get or keep an erection that is firm enough for intercourse? *Yes, every timeYes, oftenYes, on occasionYes, but rarelyI never have a problem getting or maintaining an erection for as long as I wantPreviousNextWhen did your erectile dysfunction begin? Select the option that best describes you: *Gradually, but has worsened over timeSuddenly, but with the same partnerSuddenly, with a new partnerI do not recall how it beganPreviousNextDo you get an erection... *While masturbatingWhen you wake upWhile masturbating & when you wake up None of the abovePreviousNextWhile masturbating, are you able to maintain your erection until orgasm or completion? *No, it starts hard but never remains hardYes, but only rarelyYes, on occasionYes, oftenYes, alwaysPreviousNextHow often do you wake up with an erection? *RarelySometimesEverytimePreviousNextWhich of the following best describes your sex drive or desire to have sex (libido)? *Less than it wasLess than it was because I know I have trouble with erectionsLess and it started before I had trouble with erectionsLess but I don't know which came first (less desire or trouble with erections)UnchangedPreviousNextHave you ever been formally treated for ED or tried any medication, vitamins, or supplements to treat it?YesNoPreviousNextWhich of the following treatments have you used to treat your ED in the past? *Viagra (Sildenafil)Cialis (Tadalafil)Levitra (Vardenafil)Stendra (Avanafil)OtherPreviousNextFor each treatment that you’ve tried, how effective was it in treating your ED? *This information helps your doctor better understand your particular case of ED and how your body's response to past treatments. If you have responded well to a specific medication, or poorly to another, it may impact your recommended course of treatment. PreviousNextDid you experience any side effects from past treatments for ED? *YesNoPreviousNextPlease describe any and all side effects you may have experienced from previous ED treatments: *PreviousNextHave you had a physical exam with a healthcare provider in the past 3 years?Yes, it was normalYes, but there were issuesNoPreviousNextPlease describe any issues you had during your last physical exam: *PreviousNextHave you ever been diagnosed with *High blood pressureLow blood pressureBoth high blood pressure & low blood pressureNone of the abovePreviousNextBlood PressureWe'll now need some information about your blood pressure.PreviousNextHave you had your blood pressure measured in the past 6 months? *YesNoWe are unable to continue with your assessment until we have your blood pressure readings. Please head down to your nearest pharmacy (e.g. Guardian), polyclinic or clinic to get your blood pressure reading before proceeding.Sorry!PreviousNextWhat is your Systolic (mmHg) reading? Between 90-180 Note: BP is read as 2 numbers - the top number is always higher than the bottom number. Example: "115/70" - 115 (systolic) 70 (diastolic) *PreviousNextWhat is your Diastolic (mmHg) reading? Between 60-120 Note: BP is read as 2 numbers - the top number is always higher than the bottom number. Example: "115/70" - 115 (systolic) 70 (diastolic) *PreviousNextPlease tell us more about your low blood pressure and/or high blood pressure *PreviousNextDo you take any medication, vitamins, or supplements on a regular basis? *YesNoPreviousNextPlease list any medication, vitamins, or dietary supplements you are currently taking, including their dosage: *Include any medicines (e.g. Lipitor, Zyrtec, Ibuprofen, Paracetamol) or any supplement taken in the past 2 weeks, even if you are not taking them daily.)PreviousNextDo you take any of the following medication? Select any or all that are applicable to you: *Nitroglycerin spray, ointment, patches or tablets (Nitro-Dur, Nitrolingual, Nitrostat, Nitromist, Nitro-Bid, Transderm-Nitro, Nitro-Time, Deponit, Minitran, Nitrek, Nitrodisc, Nitrogard, Nitroglycn, Nitrol ointment, Nitrong, Nitro-Par)Isosorbide mononitrate, or isosorbide dinitrate (Isordil, Dilatrate, Sorbitrate, Imdur, Ismo, Monoket)Other medication containing nitratesAlpha blockers, doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin)Riociguat (Adempas)None of the abovePreviousNextDo you have any allergies or allergic reactions to any medication? *YesNoPreviousNextPlease list the medication you are allergic to and their symptoms: *PreviousNextDo you have any prior medical condition or a history of surgeries/hospitalisations? *YesNoPreviousNextPlease list your prior medical condition and history of surgeries/hospitalisations: *PreviousNextDo any of the following cardiovascular risk factors apply to you? *DiabetesHigh cholesterolMy father had a heart attack or heart disease at 55 years or youngerMy mother had a heart attack or heart disease at 65 years or youngerNone of the abovePreviousNextTell us more about your diabetes: *How is your diabetes currently being treated? What is your average daily blood sugar? What was your last HA1C, and how long ago was it?PreviousNextTell us more about your high cholesterol: *PreviousNextDo you experience any of the following cardiovascular symptoms? *Chest pain or shortness of breath when climbing 2 flights of stairs or walking 4 blocksChest pain or shortness of breath during sexual activityUnexplained fainting or dizzinessProlonged cramping of the legs with exerciseAbnormal heart beats or rhythmsNone of the abovePreviousNextDo you have or have you previously been diagnosed with any of the following? *Select any or all that are applicable to you:Prostate cancerEnlarged prostate (BPH)Kidney transplant or any condition affecting the kidneyLiver diseaseMultiple Sclerosis (MS) or similar diseaseSpinal injuries and/or paralysisNeurological diseasesStomach, intestinal, or bowel ulcersHeart arrhythmias (abnormal beating of the heart)Any acquired, congenital, or developmental abnormalities of the heart including heart murmursNone of the abovePreviousNextFor the condition(s) you have selected, please provide us with more information (diagnosis and treatment): *PreviousNextIn the last 2 weeks, have you been troubled by any of the following? *Little interest or pleasure in doing thingsFeeling down, depressed, or hopelessFeeling nervous, anxious, or on edge (enough that it impairs your ability to function at work or at home)Worrying too much about different things (enough that it impairs your ability to function at work or at home)No, I have not felt down, anxious, nervous, etc. in the last 2 weeks.PreviousNextHow often have you felt this way in the last 2 weeks? *1-2 days per week (several days)3-4 days per week (more than half the days)Nearly every dayPreviousNextDo you use any of the following recreational drugs? *(strictly patient-doctor confidentiality)Poppers or RushAmyl Nitrate or Butyl NitrateCocaineCigarettesMarijuanaOtherNo I don't use any of thesePreviousNextPlease describe your use of the recreational drugs. How frequently did you use them? When was the last time you used them? *(it is important to note as it will affect your treatment)PreviousNextDo you have any of the following conditions? elect any or all that are applicable to you: *A marked curve or bend in the penis that interferes with sex, or Peyronie's DiseasePain when you get an erection or when you ejaculateA foreskin that is too tightFibrous tissue in the penis (lumps and bumps under the skin that feel hard)Physical problems (scarring or other issues related to your penis)None of the abovePreviousNextDoes the mark or curve prevent you from having sex? Is it painful? Have you sought treatment for this? If so, what kind of treatment did you receive? Please describe: *PreviousNextDoes your tight foreskin lead to pain during an erection? Does this interfere with sex? Are you able to pull your foreskin back and forth over the head of your penis? Have you received treatment for this condition? If so, what kind of treatment did you receive? Please describe: *PreviousNextDo you currently suffer from or have had any of the following conditions: *Retinitis PigmentosaAnterior Ischemic Optic Neuropathy (AION)Blood clotting disorder, abnormal bleeding or bruising, or coagulopathyStomach or intestinal ulcerA prior heart attack, heart failure, or narrowing of the arteriesStroke or severe insufficiency of the autonomic nervous systemPeripheral Vascular DiseaseAny history of QT prolongation in you - or even in your familySickle Cell Anemia, Myeloma, LeukemiaIdiopathic Hypertrophic Subaortic StenosisUse of blood thinnersNone of the abovePreviousNextPlease tell us more about the condition(s) selected. *PreviousNextIs there anything else you want your doctor to know about your current medical condition(s) or overall health? *YesNoPreviousNextPlease leave a message for your doctor here: *PreviousNextWhat medication do you prefer?Upon submitting your evaluation, a doctor will review your information and determine the best treatment plan for you. *Most PopularSildenafil$8.75/doseThe same active ingredient as Viagra®, but significantly cheaper.Spedra®$23/doseSecond generation ED treatment, effective in as little as 15 minutes.Cialis® 5mg (28 tablets)$6.9/doseDaily medication for greater flexibility.Cialis® 20mg $19.25/doseStronger dose for up to 36 hours of play.PreviousNextHow often do you anticipate taking Cialis® for sex each month? *This will determine how many monthly doses you request for a prescription.Use 16 times per monthUse 12 times per monthUse 8 times per monthUse 4 times per monthPreviousNextHow often do you anticipate taking Spedra for sex each month? *This will determine how many monthly doses you request for a prescription.Use 16 times per monthUse 12 times per monthUse 8 times per monthUse 4 times per monthPreviousNextShipment Frequency *Bundle your medication into fewer shipments to save.Every 6 months, cancel anytime Save $180 a year6-month of treatment for $462Every 3 months, cancel anytime Save $120 a year3-month of treatment for $246Every month, cancel anytime 1-month of treatment for $92PreviousNextShipment Frequency *Bundle your medication into fewer shipments to save.Every 6 months, cancel anytime Save $180 a year6-month of treatment for $96Every 3 months, cancel anytime Save $60 a year3-month of treatment for $240Every month, cancel anytime 1-month of treatment for $85PreviousNextShipment Frequency *Bundle your medication into fewer shipments to save.Every 6 months, cancel anytime Save $192 a year6-month of treatment for $924Every 3 months, cancel anytime Save $120 a year3-month of treatment for $480Every month, cancel anytime 1-month of treatment for $170PreviousNextShipment Frequency *Bundle your medication into fewer shipments to save.Every 6 months, cancel anytime Save $288 a year6-month of treatment for $1386Every 3 months, cancel anytime Save $180 a year3-month of treatment for $720Every month, cancel anytime 1-month of treatment for $255PreviousNextShipment Frequency *Bundle your medication into fewer shipments to save.Every 6 months, cancel anytime Save $384 a year6-month of treatment for $1848Every 3 months, cancel anytime Save $240 a year3-month of treatment for $960Every month, cancel anytime 1-month of treatment for $340PreviousNextShipment Frequency *Bundle your medication into fewer shipments to save.Every 6 months, cancel anytime (Save $180 a year) 6-month of treatment for $1170Every 3 months, cancel anytime (Save $120 a year) 3-month of treatment for $600Every month, cancel anytime 1-month of treatment for $210PreviousNextShipment Frequency *Bundle your medication into fewer shipments to save.Every 6 months, cancel anytime Save $360 a year6-month of treatment for $924Every 3 months, cancel anytime Save $240 a year3-month of treatment for $492Every month, cancel anytime 1-month of treatment for $184PreviousNextShipment Frequency *Bundle your medication into fewer shipments to save.Every 6 months, cancel anytime Save $540 a year6-month of treatment for $1386Every 3 months, cancel anytime Save $360 a year3-month of treatment for $738Every month, cancel anytime 1-month of treatment for $276PreviousNextShipment Frequency *Bundle your medication into fewer shipments to save.Every 6 months, cancel anytime Save $720 a year6-month of treatment for $1848Every 3 months, cancel anytime Save $480 a year3-month of treatment for $984Every month, cancel anytime 1-month of treatment for $368PreviousNextHow often do you anticipate taking Sildenafil for sex each month? *This will determine how many monthly doses you request for a prescription.Use 16 times per monthUse 12 times per monthUse 8 times per monthUse 4 times per monthPreviousNextShipment Frequency *Bundle your medication into fewer shipments to save.Every 6 months, cancel anytime Save $180 a year6-month of treatment for $210Every 3 months, cancel anytime Save $120 a year3-month of treatment for $120Every month, cancel anytime 1-month of treatment for $50PreviousNextShipment Frequency *Bundle your medication into fewer shipments to save.Every 6 months, cancel anytime Save $360 a year6-month of treatment for $420Every 3 months, cancel anytime Save $240 a year3-month of treatment for $240Every month, cancel anytime 1-month of treatment for $100PreviousNextShipment Frequency *Bundle your medication into fewer shipments to save.Every 6 months, cancel anytime Save $540 a year6-month of treatment for $630Every 3 months, cancel anytime Save $360 a year3-month of treatment for $360Every month, cancel anytime 1-month of treatment for $150PreviousNextShipment Frequency *Bundle your medication into fewer shipments to save.Every 6 months, cancel anytime Save $720 a year6-month of treatment for $840Every 3 months, cancel anytime Save $480 a year3-month of treatment for $480Every month, cancel anytime 1-month of treatment for $200PreviousNextOk great! Now we need some documents for official verification.We take every information you submit very seriously and they are only used by our doctors for diagnosis. In addition, your data is AES-256 encrypted and stored securely in our database. We also ensure encryption in transit and all traffic on Noah is SSL connection secure. Noah also complies fully with Singapore’s Personal Data Protection Act 2012.PreviousNextUpload a picture of your ID that shows your 1. Face 2. Full Name 3. NRIC 4. Date of Birth. *No PDFs. Our doctors are required by MOH to verify your identity using a government-issued ID. Your data is encrypted using an XTS-AES-256 cipher implemented on a hardware module on the instance. MessageSubmit
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