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Your Medical Evaluation

This 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.

What is your biological sex? *

Male
Female

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Name *

Full name as per your NRIC or Passport

First

Last

Please state your height? (in cm) *

Please state your weight? (in kg) *

Date of birth *//

Has it been hard to get or keep an erection that is firm enough for intercourse? *

Yes, every time
Yes, often
Yes, on occasion
Yes, but rarely
I never have a problem getting or maintaining an erection for as long as I want

When did your erectile dysfunction begin? Select the option that best describes you: *

Gradually, but has worsened over time
Suddenly, but with the same partner
Suddenly, with a new partner
I do not recall how it began

Do you get an erection... *

While masturbating
When you wake up
While masturbating & when you wake up
None of the above

While masturbating, are you able to maintain your erection until orgasm or completion? *

No, it starts hard but never remains hard
Yes, but only rarely
Yes, on occasion
Yes, often
Yes, always

How often do you wake up with an erection? *

Rarely
Sometimes
Everytime

Which of the following best describes your sex drive or desire to have sex (libido)? *

Less than it was
Less than it was because I know I have trouble with erections
Less and it started before I had trouble with erections
Less but I don't know which came first (less desire or trouble with erections)
Unchanged

Have you ever been formally treated for ED or tried any medication, vitamins, or supplements to treat it?

Which of the following treatments have you used to treat your ED in the past? *

Viagra (Sildenafil)
Cialis (Tadalafil)
Levitra (Vardenafil)
Stendra (Avanafil)
Other

For 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.

Did you experience any side effects from past treatments for ED? *

Please describe any and all side effects you may have experienced from previous ED treatments: *

Have you had a physical exam with a healthcare provider in the past 3 years?

Yes, it was normal
Yes, but there were issues
No

Please describe any issues you had during your last physical exam: *

Have you ever been diagnosed with *

High blood pressure
Low blood pressure
Both high blood pressure & low blood pressure
None of the above

Blood Pressure

We'll now need some information about your blood pressure.

Have you had your blood pressure measured in the past 6 months? *

We 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!

What 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) *

What 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) *

Please tell us more about your low blood pressure and/or high blood pressure *

Do you take any medication, vitamins, or supplements on a regular basis? *

Please 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.)

Do 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 nitrates
Alpha blockers, doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin)
Riociguat (Adempas)
None of the above

Do you have any allergies or allergic reactions to any medication? *

Please list the medication you are allergic to and their symptoms: *

Do you have any prior medical condition or a history of surgeries/hospitalisations? *

Please list your prior medical condition and history of surgeries/hospitalisations: *

Do any of the following cardiovascular risk factors apply to you? *

Diabetes
High cholesterol
My father had a heart attack or heart disease at 55 years or younger
My mother had a heart attack or heart disease at 65 years or younger
None of the above

Tell 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?

Tell us more about your high cholesterol: *

Do you experience any of the following cardiovascular symptoms? *

Chest pain or shortness of breath when climbing 2 flights of stairs or walking 4 blocks
Chest pain or shortness of breath during sexual activity
Unexplained fainting or dizziness
Prolonged cramping of the legs with exercise
Abnormal heart beats or rhythms
None of the above

Do you have or have you previously been diagnosed with any of the following? *

Select any or all that are applicable to you:

Prostate cancer
Enlarged prostate (BPH)
Kidney transplant or any condition affecting the kidney
Liver disease
Multiple Sclerosis (MS) or similar disease
Spinal injuries and/or paralysis
Neurological diseases
Stomach, intestinal, or bowel ulcers
Heart arrhythmias (abnormal beating of the heart)
Any acquired, congenital, or developmental abnormalities of the heart including heart murmurs
None of the above

For the condition(s) you have selected, please provide us with more information (diagnosis and treatment): *

In the last 2 weeks, have you been troubled by any of the following? *

Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Feeling 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.

How 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 day

Do you use any of the following recreational drugs? *

(strictly patient-doctor confidentiality)

Poppers or Rush
Amyl Nitrate or Butyl Nitrate
Cocaine
Cigarettes
Marijuana
Other
No I don't use any of these

Please 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)

Do 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 Disease
Pain when you get an erection or when you ejaculate
A foreskin that is too tight
Fibrous 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 above

Does 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: *

Does 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: *

Do you currently suffer from or have had any of the following conditions: *

Retinitis Pigmentosa
Anterior Ischemic Optic Neuropathy (AION)
Blood clotting disorder, abnormal bleeding or bruising, or coagulopathy
Stomach or intestinal ulcer
A prior heart attack, heart failure, or narrowing of the arteries
Stroke or severe insufficiency of the autonomic nervous system
Peripheral Vascular Disease
Any history of QT prolongation in you - or even in your family
Sickle Cell Anemia, Myeloma, Leukemia
Idiopathic Hypertrophic Subaortic Stenosis
Use of blood thinners
None of the above

Please tell us more about the condition(s) selected. *

Is there anything else you want your doctor to know about your current medical condition(s) or overall health? *

Please leave a message for your doctor here: *

What 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.

How 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 month
Use 12 times per month
Use 8 times per month
Use 4 times per month

How 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 month
Use 12 times per month
Use 8 times per month
Use 4 times per month

Shipment Frequency *