info@pandaygroup.com
|
905 773 7939
Consulting and Design
Medical Cannabis
Patient Assessment Form
Cannabis Licensing Application Guide
Cannabis Renewal
Wellness
Wellness Assessment Form
Performance Form
Wellness & Performance Refill
Store
My account
Request a Quote
Contact
Menu
Consulting and Design
Medical Cannabis
Patient Assessment Form
Cannabis Licensing Application Guide
Cannabis Renewal
Wellness
Wellness Assessment Form
Performance Form
Wellness & Performance Refill
Store
My account
Request a Quote
Contact
Search
Close
Wellness Assessment Form
Wellness
The Panday Group's Wellness & Performance Assessment Provides our Licensed Health Practitioners a Full Overview of Your Daily and Life Habits
Name
(Required)
First
Last
Please place the address you would like your medication delivered too
(Required)
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Best Contact Phone Number
(Required)
Email
(Required)
What's your gender
(Required)
Male
Female
Transgener/Non-binary
We understand these options aren't comprehensive, but this is for hormonal purposes
Date of Birth (mm/dd/yyyy)
MM slash DD slash YYYY
What is your weight ?
(Required)
Please upload 2 forms of government issued identification
(Required)
Drop files here or
Select files
Accepted file types: jpg, jpeg, ldf, gif, png, Max. file size: 80 MB, Max. files: 4.
Forms of government identification include driver's license, health card, passport etc. We do not bill any provincial insurance
How can we help you today ?
(Required)
Start using ED medication for the first time
I am taking ED meds now and want to get a new prescription
I am not taking ED meds now but want to start taking it again
I am taking ED meds now but want to change my medication
What ED symptoms have you noticed in the last 12 months?
(Required)
Difficulty getting an erection
Difficulty maintaining an erection during sexual activity
Ejaculate too quickly/premature ejaculation
Please tell us about the ED medications you have used or are currently using, the doses and how effective they were.
When did you first notice problems achieving or maintaining erections?
(Required)
Less than a month ago
Less than a month ago
More than 6 months ago
Tell us more about the other symptoms you have been experiencing.
When do you experience these symptoms?
(Required)
Every time I engage in sexual activity
When I am stressed or anxious
When I drink alcohol
When I am with a new sexual partner
Other
Select All
Do you have problems getting or maintaining an erection while masturbating?
(Required)
Yes
No
Not sure, I don't masturbate often
Do you get erections during the night or when you wake up in the morning?
(Required)
Yes
Sometimes
Rarely or Never
Do you smoke tobacco, vape nicotine, and/or use other tobacco products?
(Required)
Yes
No
What type of tobacco product do you use, how much and how often?
Have you had blood work done to check for diabetes in the last 2 years?
(Required)
Yes
No
Erectile dysfunction can be caused by underlying diseases, like diabetes.
What was your most recent blood pressure reading?
(Required)
Low - Normal120/80 or lower
Above Normalbetween 121/80 to 129/80
High between 130/81 to 139/89
Higher greater than 140/90
I don't know my blood pressure
Your blood pressure helps us determine if it is safe for you to use certain types of ED medications. We require that you are honest about your blood pressure and that your blood pressure was taken within the last 6 months.
Confirm
(Required)
We suggest that you have blood work and a physical examination to rule out other causes of erectile dysfunction, like diabetes, low testosterone or vascular disease. Please organize this with your primary care provider at your convenience.
By continuing with the application, you confirm reading and acknowledging this warning.
Was your blood work normal?
(Required)
Yes
No
Describe your experience when you walk up two flights of stairs or 20 blocks on flat terrain:
(Required)
These activities don't cause me any problems
Sometimes these activities cause me shortness of breath
Sometimes these activities cause me chest pain
Do you use any recreational drugs? Some drugs may cause life-threatening interactions with ED medications.
(Required)
Amyl Nitrate or Butyl Nitrate
Cocaine or Crack
Poppers or Rush
Cannabis
Other
Select all that apply
Are big life changes or stressors happening to you right now?
(Required)
None
Lots of new stress
Some Minor Stress
Not sure
Agreement
(Required)
I agree to the privacy policy.
While we provide medication to help, erectile dysfunction (ED) is best treated when you also address your lifestyle. We recommend regular exercise, a healthy diet, adequate sleep and stress reduction. Remember, some variation in sexual performance is completely normal, especially when involving a new partner or the use of drugs or alcohol. Medication should be used to support you while you work on lifestyle approaches to ED. Medication should not be relied upon as the only approach to treatment. Some men also require therapy when anxiety is a major cause of ED.
By continuing with the application, you confirm reading and acknowledging this message
Do any of the following currently apply to you?
(Required)
Cancer
Kidney Problems
Liver Problems
Lung or pulmonary problems
Nerve or neurological problems
Using steroids or hormones
None of these apply to me
Select All
Select all that apply
Have you ever had any of the following medical conditions?
(Required)
Abnormal heartbeat, arrhythmia, or congenital QT prolongation
Chest pain or shortness of breath
Condition where you've been told sex is not advised
Diabetes
Eye or vision problems
Heart attack, chest pain, or angina
Heart valve problems or cardiomyopathy
Low blood pressure
Pain when you have an erection
Paralysis
Passing out or fainting
Peyronie's disease
Physical problems, scarring, or other issues related to your penis
Previous prostate or pelvis surgery
Prostate problems
Radiation therapy of the pelvis
Sickle cell anemia
Spinal problems
Stroke or Transient Ischemic Attack (TIA)
Testosterone deficiency
Using nitroglycerin, isosorbide, or any other nitrate medicine
None of these apply to me
Select all that apply
Do you have any allergies
Add
Remove
This information is important. Enter all types of allergies, including skin allergies and reactions.
Do you take any medication, vitamins, herbals, or supplements?
Add
Remove
Please enter all medications you currently take, including any and all medications containing Nitroglycerine as well as vitamins, herbals, and supplements.
Have you had any surgeries or hospitalizations?
Add
Remove
Please enter any and all past surgeries below
Do you have any medical conditions?
Add
Remove
Please enter any and all medical conditions below
AMS Questionnaire
Which of the following symptoms apply to you at this time? Please mark the appropriate box for each symptom. For symptoms that do not apply, please mark "none"
Decline in your feeling of general well-being
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
(general state of health, subjective feeling)
Joint pain and muscular ache
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
(lower back pain, joint pain, pain in a limb, general back ache)
Excessive sweating
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
(unexpected/sudden episodes of sweating, hot flashes independent of strain)
Sleep Problems
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
(difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)
Increased need for sleep, often feeling tired
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Irritability
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
(feeling aggressive, easily upset about little things, moody) .
Nervousness
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
(inner tension, restlessness, feeling fidgety)
Anxiety
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
(feeling panicky)
Physical exhaustion / lacking vitality
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
(general decrease in performance, reduced activity, lacking interest in leisure activities, feeling of gelling less done, of achieving less, of having to force oneself to undertake activities)
Decrease in muscular strength
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
(feeling of weakness)
Depressive mood
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
(feeling down, sad, on the verge of tears, lack of drive. mood swings. feeling nothing is of any use)
Feeling that you have passed your peak
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Feeling burnt out, having bit rock-bottom
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Decrease in beard growth
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Decrease in ability/frequency to perform sexually
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Decrease in the number of morning erections
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
Decrease in sexual desire/libido
1 - None
2 - Mild
3 - Moderate
4 - Severe
5 - Extremley Severe
(lacking pleasure in sex, lacking desire for sexual intercourse)
Have you got any other major symtoms ?
Yes
No
If Yes, please describe:
Do you have any questions you would like to ask the healthcare practitioner about prescription ED medication?
Please type above
Prescription Visit
(Required)
First Time Appointment
Refill Appointment
Payment of $100 will be requested for the health practitioner consult prior to the appointment. Payment must be made within 24 hrs to ensure a health practitioner is available for the requested time and date. The remaining $100 will be requested ONLY if our health practitioner issues a prescription.
Choose your preferred medication
(Required)
PLEASE CHOOSE AN OPTION BELOW
I don't know I need assistance from a health practitioner
COMBO MIXTURE (Viagara/Cialis)
Sildenafil 25mg Tadalafil 10mg -10 Pills
Sildenafil 50mg Tadalafil 20mg - 10 Pills
Sildenafil 75mg Tadalafil 20mg -10 Pills
Sildenafil 100mg Tadalafil 20mg - 10 Pills
BRAND NAME
Cialis 2.5mg - 28 Pills
Cialis 5mg - 28 Pills
Cialis 10mg - 4 Pills
Cialis 20mg - 4 Pills
Viagra 25mg - 4 Pills
Viagra 50mg - 4 Pills
Viagra 100mg - 4 Pills
GENERIC
Apo-Sildenafil 25mg - 4 Pills
Apo-Sildenafil 50mg - 4 Pills
Apo-Sildenafil 100mg - 4 Pills
Apo-Tadalafil 2.5mg - 30 Pills
Apo-Tadalafil 5mg - 30 Pills
Apo-Tadalafil 10mg - 4 Pills
Apo-Tadalafil 20mg - 4 Pills
Your healthcare practitioner will take your choice into consideration and prescribe the medication best suited for you.
Additional Medication
Additional Choices
Lubricants (Premature Ejaculation) Lidocaine 5% Tetracaine 5% Liquid - 50 Liquid Lubricant
Total
Medication payment will be requested prior to shipping. Please note payment will be requested by Interact E-Transfer.
Hidden
Untitled
ED Wellness
Consulting
Medical Cannabis Renewal Appointment Request
Pick a Date & Time For an Appointment with the Health Practitioner
May 2022
Sun
Mon
Tue
Wed
Thu
Fri
Sat
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
May 21, 2022
6:45 PM - 7:00 PM
7:05 PM - 7:20 PM
7:25 PM - 7:40 PM
7:45 PM - 8:00 PM
8:05 PM - 8:20 PM
8:25 PM - 8:40 PM
8:45 PM - 9:00 PM
9:05 PM - 9:20 PM
9:25 PM - 9:40 PM
9:45 PM - 10:00 PM
May 23, 2022
9:00 AM - 9:15 AM
9:20 AM - 9:35 AM
9:40 AM - 9:55 AM
10:00 AM - 10:15 AM
10:20 AM - 10:35 AM
10:40 AM - 10:55 AM
11:00 AM - 11:15 AM
11:20 AM - 11:35 AM
11:40 AM - 11:55 AM
5:00 PM - 5:15 PM
5:20 PM - 5:35 PM
5:40 PM - 5:55 PM
6:00 PM - 6:15 PM
6:20 PM - 6:35 PM
6:40 PM - 6:55 PM
7:00 PM - 7:15 PM
7:20 PM - 7:35 PM
7:40 PM - 7:55 PM
8:00 PM - 8:15 PM
8:20 PM - 8:35 PM
8:40 PM - 8:55 PM
9:00 PM - 9:15 PM
9:20 PM - 9:35 PM
9:40 PM - 9:55 PM
May 24, 2022
9:00 AM - 9:15 AM
9:20 AM - 9:35 AM
9:40 AM - 9:55 AM
10:00 AM - 10:15 AM
10:20 AM - 10:35 AM
10:40 AM - 10:55 AM
11:00 AM - 11:15 AM
11:20 AM - 11:35 AM
11:40 AM - 11:55 AM
5:05 PM - 5:20 PM
5:25 PM - 5:40 PM
5:45 PM - 6:00 PM
6:05 PM - 6:20 PM
6:25 PM - 6:40 PM
6:45 PM - 7:00 PM
7:05 PM - 7:20 PM
7:25 PM - 7:40 PM
7:45 PM - 8:00 PM
8:05 PM - 8:20 PM
8:25 PM - 8:40 PM
8:45 PM - 9:00 PM
9:05 PM - 9:20 PM
9:25 PM - 9:40 PM
9:45 PM - 10:00 PM
May 25, 2022
9:00 AM - 9:15 AM
9:20 AM - 9:35 AM
9:40 AM - 9:55 AM
10:00 AM - 10:15 AM
10:20 AM - 10:35 AM
10:40 AM - 10:55 AM
11:00 AM - 11:15 AM
11:20 AM - 11:35 AM
11:40 AM - 11:55 AM
5:05 PM - 5:20 PM
5:25 PM - 5:40 PM
5:45 PM - 6:00 PM
6:05 PM - 6:20 PM
6:25 PM - 6:40 PM
6:45 PM - 7:00 PM
7:05 PM - 7:20 PM
7:25 PM - 7:40 PM
7:45 PM - 8:00 PM
8:05 PM - 8:20 PM
8:25 PM - 8:40 PM
8:45 PM - 9:00 PM
9:05 PM - 9:20 PM
9:25 PM - 9:40 PM
9:45 PM - 10:00 PM
May 26, 2022
9:00 AM - 9:15 AM
9:20 AM - 9:35 AM
9:40 AM - 9:55 AM
10:00 AM - 10:15 AM
10:20 AM - 10:35 AM
10:40 AM - 10:55 AM
11:00 AM - 11:15 AM
11:20 AM - 11:35 AM
11:40 AM - 11:55 AM
5:05 PM - 5:20 PM
5:25 PM - 5:40 PM
5:45 PM - 6:00 PM
6:05 PM - 6:20 PM
6:25 PM - 6:40 PM
6:45 PM - 7:00 PM
7:05 PM - 7:20 PM
7:25 PM - 7:40 PM
7:45 PM - 8:00 PM
8:05 PM - 8:20 PM
8:25 PM - 8:40 PM
8:45 PM - 9:00 PM
9:05 PM - 9:20 PM
9:25 PM - 9:40 PM
9:45 PM - 10:00 PM
May 27, 2022
9:00 AM - 9:15 AM
9:20 AM - 9:35 AM
9:40 AM - 9:55 AM
10:00 AM - 10:15 AM
10:20 AM - 10:35 AM
10:40 AM - 10:55 AM
11:00 AM - 11:15 AM
11:20 AM - 11:35 AM
11:40 AM - 11:55 AM
5:05 PM - 5:20 PM
5:25 PM - 5:40 PM
5:45 PM - 6:00 PM
6:05 PM - 6:20 PM
6:25 PM - 6:40 PM
6:45 PM - 7:00 PM
7:05 PM - 7:20 PM
7:25 PM - 7:40 PM
7:45 PM - 8:00 PM
8:05 PM - 8:20 PM
8:25 PM - 8:40 PM
8:45 PM - 9:00 PM
9:05 PM - 9:20 PM
9:25 PM - 9:40 PM
9:45 PM - 10:00 PM
May 28, 2022
9:00 AM - 9:15 AM
9:20 AM - 9:35 AM
9:40 AM - 9:55 AM
10:00 AM - 10:15 AM
10:20 AM - 10:35 AM
10:40 AM - 10:55 AM
11:00 AM - 11:15 AM
11:20 AM - 11:35 AM
11:40 AM - 11:55 AM
5:05 PM - 5:20 PM
5:25 PM - 5:40 PM
5:45 PM - 6:00 PM
6:05 PM - 6:20 PM
6:25 PM - 6:40 PM
6:45 PM - 7:00 PM
7:05 PM - 7:20 PM
7:25 PM - 7:40 PM
7:45 PM - 8:00 PM
8:05 PM - 8:20 PM
8:25 PM - 8:40 PM
8:45 PM - 9:00 PM
9:05 PM - 9:20 PM
9:25 PM - 9:40 PM
9:45 PM - 10:00 PM
May 30, 2022
9:00 AM - 9:15 AM
9:20 AM - 9:35 AM
9:40 AM - 9:55 AM
10:00 AM - 10:15 AM
10:20 AM - 10:35 AM
10:40 AM - 10:55 AM
11:00 AM - 11:15 AM
11:20 AM - 11:35 AM
11:40 AM - 11:55 AM
5:00 PM - 5:15 PM
5:20 PM - 5:35 PM
5:40 PM - 5:55 PM
6:00 PM - 6:15 PM
6:20 PM - 6:35 PM
6:40 PM - 6:55 PM
7:00 PM - 7:15 PM
7:20 PM - 7:35 PM
7:40 PM - 7:55 PM
8:00 PM - 8:15 PM
8:20 PM - 8:35 PM
8:40 PM - 8:55 PM
9:00 PM - 9:15 PM
9:20 PM - 9:35 PM
9:40 PM - 9:55 PM
May 31, 2022
9:00 AM - 9:15 AM
9:20 AM - 9:35 AM
9:40 AM - 9:55 AM
10:00 AM - 10:15 AM
10:20 AM - 10:35 AM
10:40 AM - 10:55 AM
11:00 AM - 11:15 AM
11:20 AM - 11:35 AM
11:40 AM - 11:55 AM
5:05 PM - 5:20 PM
5:25 PM - 5:40 PM
5:45 PM - 6:00 PM
6:05 PM - 6:20 PM
6:25 PM - 6:40 PM
6:45 PM - 7:00 PM
7:05 PM - 7:20 PM
7:25 PM - 7:40 PM
7:45 PM - 8:00 PM
8:05 PM - 8:20 PM
8:25 PM - 8:40 PM
8:45 PM - 9:00 PM
9:05 PM - 9:20 PM
9:25 PM - 9:40 PM
9:45 PM - 10:00 PM
By initializing and / or signing this document, you affirm that all of the information in this Medical Wellness Agreement is true and you agree to all of the ASSESSMENT, MEDICAL HISTORY, AGREEMENTS, ACKNOWLEDGEMENTS, and terms hereof.
(Required)