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)
Please place the address you would like your medication delivered too(Required)
What's your gender(Required)
We understand these options aren't comprehensive, but this is for hormonal purposes
MM slash DD slash YYYY
Drop files here or
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)
    What ED symptoms have you noticed in the last 12 months?(Required)
    When did you first notice problems achieving or maintaining erections?(Required)
    When do you experience these symptoms?(Required)
    Do you have problems getting or maintaining an erection while masturbating?(Required)
    Do you get erections during the night or when you wake up in the morning?(Required)
    Do you smoke tobacco, vape nicotine, and/or use other tobacco products?(Required)
    Have you had blood work done to check for diabetes in the last 2 years?(Required)
    Erectile dysfunction can be caused by underlying diseases, like diabetes.
    What was your most recent blood pressure reading?(Required)
    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)
    Was your blood work normal?(Required)
    Describe your experience when you walk up two flights of stairs or 20 blocks on flat terrain:(Required)
    Do you use any recreational drugs? Some drugs may cause life-threatening interactions with ED medications.(Required)
    Select all that apply
    Are big life changes or stressors happening to you right now?(Required)
    Agreement(Required)
    Do any of the following currently apply to you?(Required)
    Select all that apply
    Have you ever had any of the following medical conditions?(Required)
    Select all that apply
    Do you have any allergies
    This information is important. Enter all types of allergies, including skin allergies and reactions.
    Do you take any medication, vitamins, herbals, or supplements?
    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?
    Please enter any and all past surgeries below
    Do you have any medical conditions?
    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
    (general state of health, subjective feeling)
    Joint pain and muscular ache
    (lower back pain, joint pain, pain in a limb, general back ache)
    Excessive sweating
    (unexpected/sudden episodes of sweating, hot flashes independent of strain)
    Sleep Problems
    (difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)
    Increased need for sleep, often feeling tired
    Irritability
    (feeling aggressive, easily upset about little things, moody) .
    Nervousness
    (inner tension, restlessness, feeling fidgety)
    Anxiety
    (feeling panicky)
    Physical exhaustion / lacking vitality
    (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
    (feeling of weakness)
    Depressive mood
    (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
    Feeling burnt out, having bit rock-bottom
    Decrease in beard growth
    Decrease in ability/frequency to perform sexually
    Decrease in the number of morning erections
    Decrease in sexual desire/libido
    (lacking pleasure in sex, lacking desire for sexual intercourse)
    Have you got any other major symtoms ?
    Please type above
    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.
    Your healthcare practitioner will take your choice into consideration and prescribe the medication best suited for you.
    Medication payment will be requested prior to shipping. Please note payment will be requested by Interact E-Transfer.
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