- UBI Telehealth

First up

Answer a few questions so we can help

In which state do you currently reside?

State is required

We regret to inform you that we do not currently service to your area of residence. Our shipping services are temporarily limited to the following states: FL. We apologize for any inconvenience and appreciate your understanding.

What is your Date of Birth?

This field is required Please enter valid date

Thank you for visiting UBI Telehealth. Our products are intended only for those who are 18 years of age or older, in accordance with legal and medical guidelines. Please consult with your primary care provider for a personalized treatment plan that is both safe and effective for you. We invite you to browse our other available products, as there may be an alternative that better suits your needs.

What was your sex assigned at birth?

Male

Female

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How frequently do you experience difficulty in achieving or maintaining an erection during sexual activity?

Always

Sometimes

Occasionally

Rarely

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What outcomes are you aiming for?

Achieving and maintaining an erection during sexual activity

Improve Libido

Both of the above

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In the last 6 months, how do you rate your confidence that you could get and keep an erection?

Very Low

Low

Moderate

High

Very High

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In the last 6 months, when you had erections with sexual stimulation,how often were your erections hard enough for penetration?

Almost never or never

Much less than half the time

About half of the time

Much more than half of the time

Almost always or always

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In the last 6 months, during sexual intercourse,how often were you able to maintain your erection after you had penetrated (entered) your partner?

Almost never or never

Much less than half the time

About half of the time

Much more than half of the time

Almost always or always

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In the last 6 months, during sexual intercourse,how difficult was it to maintain your erection to completion of intercourse?

Extremely difficult

Very difficult

Difficult

Slightly difficult

Not difficult

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In the last 6 months, when you attempted sexual intercourse,how often was it satisfactory for you?

Almost never or never

Much less than half the time

About half of the time

Much more than half of the time

Almost always or always

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Have you had a physical exam from your physician in the last 3 years?

Yes

This field is required Please consult with your primary care physician for this treatment.

What is your last systolic blood pressure (top number)?

90 to 160 mmHg

Less than 90 mmHg

161 mmHg or higher

This field is required Please consult with your primary care physician for this treatment.

Is your last diastolic blood pressure (bottom number) LOWER than 50 mmHg?

Yes

This field is required Please consult with your primary care physician for this treatment.

Are you taking sublingual nitroglycerine/nitrates for chest pain?

Yes

This field is required

Do you have a history of any of the following:

None of the below

Peyronie's disease or other disorders of penile deformity

History of priapism

Sickle cell disease

Active stomach ulcer

History of Retinitis Pigmentosa

History of visual loss related to disease of optic nerve such as optic neuritis

History of liver disease (including cirrhosis)

History of kidney (renal) impairment

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Are you on any of the following medications?

Amiodarone (Cardarone, Pacerone)
Pimozide (Orap)
Riociguat(Adempas)
Sotalol (Betapace, Sorine, Sotylize)
Ibutilide (Corvert)
Nitroglycerine
Nitroprusside
Thioridazine (Mellaril)
Vericiguat (Verquvo)
Dronedarone (Multaq)

Quinidine (Quinaglute, Quinidex)
Iefamulin (Xenleta)
Abilify
Procainamide (Pronestyle, Procan, Procanbid)
Accupril (Quinapril)
Disopyramide (Norpace, Rhythmodan)
Isosorbide dinitrate
Isosorbide mononitrate
Iefamulin (Xenleta)

Yes, I am taking one or more of these medications

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List your Medication Allergies

No known allergies

Please list any allergies you have?

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Have you taken Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra), or Avanafil (Stendra) in the past?

Yes

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Please type in name of the medication you have previously taken for ED and dosage?

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Was the medication effective?

Yes

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Did you have undesirable side effects or allergic reaction?

Yes

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Please list any side effects you experienced

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What is your zip code?

Enter your zip code:

Zip is required Enter valid zip code

Thank you for visiting UBI Telehealth. This workflow pertains to male erectile dysfunction. Please refer back to product list for women.

Do you smoke?

Yes

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How many packs a day

Less than half ppd

Half ppd

One ppd

More than one ppd

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For how long?

Less than one year

1-5 years

5-10 years

More than 10 years

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Do you regularly consume more than two alcoholic beverages per day?

Yes

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Do you often consume more than 14 alcoholic beverages per week?

Yes

This field is required

Have you been advised by your physician to avoid excessive physical activity?

Yes

This field is required

In the past three months, have you had chest pain that limits your physical activity?

Yes

This field is required