Myonlinedoctor Erectile dysfunction treatment Registration Page

Have you ever used any form of hormonal contraceptive before. (such as the pill, nuvaring, or evra patch)

Yes No

Name of all the contraceptives you have used in the past?

Are you currently using a contraceptive?

Yes No

How long have you been using this treatment for, and who prescribed it for you?

Have you experienced any side effects or problems since taking this Pill such as irregular bleeding?

Yes No

When was your last face-to-face check up with your regular doctor?

Do you smoke?

Yes No

Is there a history of Deep Vein Thrombosis or other blood clotting disorders in your family?

Yes No

Do you suffer from: Migraine, Diabetes, Cancer, Liver Disease?

Yes No

Are you taking any of the following medications: Carbamazepine, griseofulvin, modafinil, nelfinavir, nevirapine, oxcarbazepine, phenytoin, phenobarbital, primidone, ritonavir, St John's Wort, topiramate, rifabutin or rifampicin?

Yes No

Do you suffer from acne or hirsutism?

Yes No

Which contraceptive do you plan to order and who suggested you try it?

What is your latest blood pressure and when was it done?

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