This form is put up as a template.  Look at the column on the right for special notes and comments.  There is a   "mail to"  on the end which can be used as feedback.  Please use it to send any comments.  Thanks.

Village Apothecary Secure Order Form
Patient Information:

 

  - Salutation  
  - First Name  
  - Last Name  
  - Middle Initial  
     
  - Street Address  
  - Suite, Floor  
  - City  
  - State  
  - Zip  
  - E-Mail Address  
  - Daytime Phone  
  - Evening Phone  
     
  - How did you hear about us?  
     
Patient Details:
  - Height?  
  - Weight?  
  - Date of Birth?  
  - Sex? (M/F)  
     
  - Do you smoke cigars or cigarettes?  
  - How many cigars a day?  
  - How many packs of cigarettes a day?  
  - Do you consume more than 2 servings of alcohol a day?  
     
     
General Medical Information:
  - How is your blood pressure?  
  - Do you have high cholesterol?  
  - Have you had a complete physical examination with blood workups within the last year?  
  - Do you have any allergies to any medication?  
  - Do you have any allergies to anything?  
  - Do any diseases or disorders run in your family?  
  - Please list any medical conditions for which you are receiving treatment at this time? (Enter none if you are not being treated)  
  - Please provide you past surgical history  
  - Do you consider anything else in your medical history relevant?  
     
Have you been diagnosed or do you suffer from any of the following conditions? (please check all that apply).
     
  Coronary Artery Disease  
  Congestive Heart Failure  
  Valvular Heart Disease  
  Anatomic Deformation of the Penis  
  Peyronies Disease  
  Multiple Myeloma  
  Obesity  
  Hypertension  
  Diabetes Mellitus  
  Prostate Cancer  
  Enlarged Prostate  
  Low Testosterone  
  Thyroid Disease  
  Atherosclerosis  
  Liver Disease  
  Kidney Disease  
  Stroke  
  Depression  
  Anxiety  
  Schizophrenia  
  Spinal Cord Injury  
  Endocrine Disorders  
  Sickle Cell Anemia  
  Leukemia  
  Retinitus Pigmentosa  
  Low or High Blood Pressure  
  HIV  
  Syphilus  
  Herpes  
     
Primary Physician Information:
  - Name:  
  - Address:  
  - Contact Information (i.e. Phone Number):  
     
You must fill  in this section if you are a female:
  - Are you currently pregnant?  
  - Are you currently breast feeding?  
  - Do you plan to become pregnant within the next year?  
     
     
Questions for Viagra:
  - Have you ever been evaluated for erectile dysfunction?  
  - Have you ever had an erection which lasted more than four hours?  
  - Do you have a crooked penis (Peyronies Disease)?  
  - Do you have a deformed penis?  
  - Are you unable to have an erection until orgasm?  
  - Do you feel you must have medication in order to have satisfying sex?  
     
Nitrate Medications:
Are you currently taking any of the following medications? Check ALL that apply.  
     
  Nitroglycerin  
  Nitrek (transdermal)  
  Nitro-Bid  
  Nitrodisc  
  Nitro-Dur  
  Nitrogard  
  Nitroglyn  
  Nitrilingual Spray  
  Nitrol Ointment (Appol-Kit)  
  Nitrong  
  Nitro-Par  
  NitroStar  
  Nitro-Time  
  Transderm-Nitro  
  Isosorbide Mononitrate  
  Imdur  
  Ismo  
  Monoket  
  Isosorbide Dinitrate  
  Dialarate-SR  
  Isordil  
  Sorbitrate  
  Erythatyl Tentranitrate  
  Pentaerythritol Tetranitrate  
  Sodium Nitroprusside  
     
     
  Comments on this form can be mailed to stam@xylas.com  
     
     
     
     
     
     
     
     
     
     
     
  This is a test field do not use.