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Mapeo Completo Test

The document lists all 50 U.S. states, followed by text indicating that the provider needs to be licensed in the user's state of residence. It then continues with several screens of a medical history questionnaire that collects information about the user's health, medical conditions, medications, lifestyle, and sexual health. The questionnaire appears to be part of an online consultation or telehealth process for evaluating erectile dysfunction or a related condition.

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Valeria Valderrama
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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12 views8 pages

Mapeo Completo Test

The document lists all 50 U.S. states, followed by text indicating that the provider needs to be licensed in the user's state of residence. It then continues with several screens of a medical history questionnaire that collects information about the user's health, medical conditions, medications, lifestyle, and sexual health. The questionnaire appears to be part of an online consultation or telehealth process for evaluating erectile dysfunction or a related condition.

Uploaded by

Valeria Valderrama
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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First, we need to make sure we are licensed in your state.

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada
New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota
Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

I agree to the Terms, Privacy Policy and consent to Telehealth

What's your email address?

On the following screens we will collect information about your health, medical history, and
lifestyle.

First name:

Last name:

Date of birth:

Do you have any medical condition?

No

Yes

Do you have any of the following medical conditions?

Heart disease

Diabetes

Hyperlipidemia

Vascular Disease

Emotional Problems

Kidney Disease

Trauma or injury to: penis, pelvis, perineum, testes, or rectum

Prostate problems

Urinary problems
Sleep apnea

Chronic fatigue or weakness

Other

Have you had a physical exam in the last three years?

Yes

No

Were there any abnormalities on your physical exam?

No

Yes

Please provide more detail on the abnormalities from your physical exam.

When was the last time you saw your primary care provider for a physical exam?

What effect, if any, have your sexual problems had on your partner relationships?

Little or no effect

Moderate effect

Large effect

With sexual stimulation can you...

Initiate an erection

Maintain an erection

Neither initiate nor maintain an erection

Please give us brief details about your selected options.

Have you taken any of the following as treatment for erectile dysfunction?

Sildenafil (Viagra)

Tadalafil (Adcirca, Cialis)

Vardenafil (Levitra, Staxyn),Avanafil (Stendra)

Testosterone Replacement

Injections

Surgery or use of Pumps

None of the above

Was the treatment(s) you selected effective?


In the last three months, have you taken any of the following drugs?

Clarithromycin

Diltiazem

Erythromycin

Itraconazole

Ketoconazole

Ritonavir

Verapamil

Doxazosin mesylate (Cardura)

Prazosin hydrochloride (Minipress)

Terazosin hydrochloride (Hytrin)

Hormones

Sedatives

Ulcer medications

None of the above

Your health is our #1 priority. If you selected one or more, please provide more details below:

Have you ever been prescribed nitrates/nitroglycerin?

No

Yes

Please provide as much detail as possible. When was the last time you were prescribed
nitrates/nitroglycerin?

In the past several months, have you had any of the following:

Chest Pain

Passing Out

Dizziness/Seizure

None of the above

Have you had any surgeries?

No

Yes
Please list all surgeries you've had:

Is there a family history of any of the following?

Cardiovascular disease

Unexplained sudden death

None of the above

Please provide details of family history of cardiovascular disease.

Over the past two weeks how often have felt little or no pleasure in activities you usually enjoy?

Not at all

Several days

More than half the days

Nearly every day

Do you drink alcohol daily or binge drink?

No

Yes

On average, how much alcohol do you drink per day?

0-1 Drink every day

1-2 Drinks every day

3-4 Drinks every day

5-6 Drinks every day

7+ Drinks every day

In The Last Three Months, Have You Used Any Of The Following Drugs Recreationally?

Cocaine

Poppers or Rush

Opiates/Heroin

Methamphetamine

Molly (MDMA)

Other

None

Please provide more details here:


Do you exercise regularly?

No

Yes

How often do you exercise?

Every day

At least 3x per week

Weekly

Less than once a week

Do you have any extra information to share with the doctor?

No

Yes

Please provide any details you would like to share with the doctor

Have you had elevated Blood pressure in the past 6 months?

No

Yes

Please provide more details:

Systolic Pressure (mmHG) Value

Diastolic Pressure (mmHG) Value

Do you have any allergies? Include any allergies to food, dyes, prescription or over-the-counter
medicines (e.g., antibiotics, allergy medications), herbs, vitamins, supplements, or anything else.

No

Yes

Please list what you are allergic to and the reaction that each allergy causes.

Are you on any medications? Include any medicines (e.g., Lipitor, Zyrtec, ibuprofen), herbs,
vitamins, or dietary supplements that you have taken in the past 2 weeks, even if you are not
taking them today.

No

Yes

Please list the current medications that you are taking

Which of the following apply to you?


I get less than 2 hours of exercise per week

I do not eat as healthy as I would like

I smoke or use tobacco (e.g., chewing tobacco, snuff)

I use other nicotine containing products (e.g., vaping)

I drink more than 2 alcoholic drinks per day

I get less than 7 hours of sleep per night, on average

I'm 25+ pounds overweight

I am frequently under a lot of stress

None apply to me

Have you experienced any of the following conditions?

Enlarged prostate

Weight gain / management

Sleep / insomnia

Hair loss

Low testosterone

Blood sugar / diabetes

Acne / Rosceca / Hyperpigmentation

Joint Issues

Toe nail fungus

Pain management

None

How many times do you anticipate using the medication, if prescribed?

4 times per month

6 times per month (Most Popular)

8 times per month

10 times per month

Thank you for taking the time to complete this survey

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