Medical Evaluation Form
Please answer all questions honestly. If you answer “Yes” to any critical question (marked with ⚠️), you
will need to schedule a consultation before purchasing.
⚠️ CRITICAL: 1. Are you currently using any
medications containing nitrates?
(Examples: Nitroglycerin, Isosorbide, or recreational drugs known as “poppers”)
medications containing nitrates?
(Examples: Nitroglycerin, Isosorbide, or recreational drugs known as “poppers”)
Note: Combined use can cause a life-threatening drop in blood pressure.
⚠️ CRITICAL: 2. Have you experienced any
cardiovascular events in the last 6 months?
(Myocardial infarction, stroke, or serious arrhythmias)
cardiovascular events in the last 6 months?
(Myocardial infarction, stroke, or serious arrhythmias)
⚠️ CRITICAL: 3. Do you suffer from heart
failure or unstable angina (chest pain)?
failure or unstable angina (chest pain)?
4. What is your usual blood pressure?
⚠️ CRITICAL: 5. Do you have a history of
vision loss due to optic neuropathy (NAION) or inherited retinal problems?
vision loss due to optic neuropathy (NAION) or inherited retinal problems?
6. Do you have any physical deformities of the penis or Peyronie’s disease?
⚠️ CRITICAL: 7. Have you been diagnosed with
severe kidney or liver failure?
severe kidney or liver failure?
8. Are you taking any other medications for erectile dysfunction or prostate problems (alpha
blockers)?
blockers)?
✓
If you answered “No” to ALL critical
questions (⚠️):
You are a candidate for purchasing
Cialis. You can proceed to place your order safely.
⚠
If you answered “Yes” to ANY critical
question (⚠️):
For your safety, we recommend
scheduling a teleconsultation or in-person consultation with Dr. Adonis before purchasing.