Do you have any chronic medical conditions?

Have you been hospitalized in the past 6 months?

Do you have any known allergies to medications or supplements?

What are your known allergies?

Do you have any implanted medical devices (e.g., pacemaker)

Question

Have you ever had surgery? If yes, list the type and date.

Do you have a primary care physician?

When was your last routine check-up?

Have you received any vaccinations in the past year?

Please list any recent lab tests or imaging performed

Have you been diagnosed with any heart conditions?

Do you experience chest pain or shortness of breath?

Do you have high blood pressure?

What is your most recent blood pressure reading (if known)?

What is your most recent blood pressure reading (if known)?

Do you take any heart medications (e.g., beta blockers, nitrates)?

Have you ever had a stroke or mini-stroke (TIA)?

Do you have a history of irregular heartbeat (arrhythmia)?

Are you currently sexually active?

Do you experience erectile dysfunction or performance issues?

Have you used erectile dysfunction medication before?

Are you currently trying to conceive?

Have you had a vasectomy or tubal ligation?

Do you experience pain during intercourse?

When was your last menstrual period?

Have you been diagnosed with depression or anxiety?

Are you currently taking medications for mental health?

Have you had thoughts of self-harm or suicide recently?

Would you like a mental health provider to follow up with you?

Do you experience trouble sleeping or insomnia?

Do you have diabetes or high blood sugar?

Are you currently taking insulin or diabetes medication?

Have you experienced unexplained weight gain or loss?

Do you have any known thyroid conditions?

What is your most recent blood sugar or HbA1c (if known)?

Do you currently smoke or use tobacco?

Do you consume alcohol?

How many hours do you sleep on average per night?

Do you follow any special diet?

Do you exercise regularly?

How often do you exercise per week?

Are you currently taking any prescription medications?

Are you taking any over-the-counter supplements or vitamins?

Have you had any past allergic reactions to medications?

Please list all current medications and dosages

What is your current weight?

What is your current height?

What is your most recent heart rate (if known)?

Do you own a blood pressure monitor?

Are you requesting this product for yourself?

Have you used this product in the past?

Have you had any side effects with similar products?

Have you reviewed the products side effects and usage instructions?

What symptoms are you currently experiencing?

Have you ever been diagnosed with any of the following conditions? (Check all that apply)

Are you currently taking any medications?

Do you have any allergies to medications?

Vital Sign Value

Heart Rate (bpm)

Body Temperature (°F)

Weight (lbs or kg)

Height (feet/in or cm)