Questionannaire ENG

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Step 1 of 22 – Questionannaire_Intro

We are here to help you with your problems as a man in Switzerland!

After answering the following questions and a short call back from a doctor, we will discreetly deliver your desired erectile dysfunction remedy to you. All your answers will be kept strictly confidential and will only be shared with a pharmacist from your canton!

Get started

Get started

In which canton do you live?

Aargau

Appenzell Innerrhoden

Appenzell Ausserrhoden

Bern

Basel-Landschaft

Basel-Stadt

Freiburg

Genf

Glarus

Graubünden

Jura

Luzern

Neuenburg

Nidwalden

Obwalden

St. Gallen

Schaffhausen

Solothurn

Schwyz

Thurgau

Tessin

Uri

Waadt

Wallis

Zug

Zürich

Do you regularly have trouble getting or keeping an erection?

Yes

Have you been having trouble with erections for more than a year?

Yes

How would you rate your confidence in getting and keeping an erection?

Didn’t try to have sex

Very low

Low

Medium

High

Very high

If you had erections during sexual stimulation, how often were your erections hard enough for penetration?

Didn’t try to have sex

(Almost) never

A few times (less than half the time)

Sometimes (approximately half the time)

Often (more than half the time)

(Almost) always

How many times were you able to maintain erection during the sexual act after penetrating your partner?

Didn’t try to have sex

(Almost) never

A few times (less than half the time)

Sometimes (approximately half the time)

Often (more than half the time)

(Almost) always

During intercourse, how difficult was it to maintain your erection until intercourse was complete?

Didn’t try to have sex

Extremely difficult

Very difficult

Difficult

Somewhat difficult

Not difficult

If you have tried to have sexual intercourse, how often was it satisfying for you?

Didn’t try to have sex

(Almost) never

A few times (less than half the time)

Sometimes (approximately half the time)

Often (more than half the time)

(Almost) always

Do you sometimes have no problems with erection? For example, when you wake up in the morning, when you masturbate or during sexual intercourse?

Yes

Thank you for your honesty!

You are not alone. 500,000 men in Switzerland suffer from erectile dysfunction.

In the next round of questions we will look into your health. You should have had a blood pressure test within the last year to answer the following questions. It is best to have your blood pressure measured regularly by doctors, nurses or pharmacists.

Agree and continue

Agree and continue

What is your current blood pressure?

Low – Below 90/160

Normal – between 90 / 160 and 140 / 90

High – above 140 / 90

We need to calculate your BMI, what is your height and weight?

Height in centimeters*

Please enter a number from 100 to 250.

Weight in kilograms*

Please enter a number from 40 to 350.

How is your alcohol consumption?

I never drink alcohol

I rarely drink alcohol, certainly not more than half a liter beer or a glass of wine per day

I regularly drink alcohol, but not more than a liter beer or half a liter wine per day

I drink more than a liter of beer or half a liter of wine per day

Tell us more about your smoking habits.

I don’t smoke

I rarely smoke, not more than half a pack per day

I smoke regularly, but in the last 5 years less than 1 pack per day

I smoke regularly, in the last 5 years, but not more than 10 years, one package per day

I smoke regularly, more than one package per day for more than 10 years

Do any of the following conditions, diseases or treatments apply to you?*

Lack of exercise (less than 2.5 hours per week)

Diabetes mellitus

Dyslipoproteinemia

Severe cardiovascular disease such as marked heart failure (NYHA III-IV heart failure), high-risk arrhythmias, moderate to severe valvular heart disease (valvulopathies), cardiomyopathies, or left ventricular dysfunction

Prostatectomy (removal of the prostate), radiation or seeds of the prostate

Surgery in the small pelvis likely to affect the neurovascular supply (e.g., rectal resection, urinary bladder removal)

Accident involving the pelvis/penis/spine

Nervous disorders and physical trauma (e.g., Parkinson’s disease, multiple sclerosis, spinal cord disease, paraplegia, traumatic brain injury)

(Neuro)psychiatric disorders (e.g. dementia)

Autoinjection therapy (SKAT, MUSE)

None of the above

Have you been diagnosed with any of the following diseases or medical events by a physician? Please select applicable.*

Allergies or other negative reactions to erectile dysfunction medications

Heart attack

Heart pain (angina pectoris)

Stroke or mini-stroke (transient ischemic attack)

Visual disturbances due to circulatory difficulties

Hereditary eye disease such as retinitis pigmentosa (RP)

Kidney or liver damage

Deformation or angulation of the penis (Peyronie)

Sickle cell disease, leukemia or Kahler’s disease (multiple myeloma)

Blood clotting disorder (hemophilia)

Active or peptic gastric ulcers (gastric ulcer)

None of the above diagnoses

Are you currently taking any of the following medications? Please select applicable.*

Other medication for erectile dysfunction than Viagra/Sildenafil, Cialis/Tadalafil, Levitra/Vardenfail or Spedra

Nitrates for heart disease, such as glycerol trinitrate, isosorbide mononitrate, isosorbide dinitrate, GTN spray/gel, or nicorandil

Ritonavir, Indinavir or drugs against HIV

Riociguat for high pulmonary blood pressure

Ketoconazole, itraconazole or other antifungal medicines

Chemical ‘party drugs’, especially amyl nitrates (poppers)

Alpha-blockers (used in part for high blood pressure or prostate enlargement) such as alfuzosin, doxazosin, indoramin, prazosin, tamsulosin, or terazosin

None of the mentioned medications

Have you been advised by a medical professional to avoid intense physical exertion? For example, because of serious heart disease or heart pain (angina pectoris or unstable angina)?

Yes

This is really helpful!

Multiple health-compromising factors are associated with erectile dysfunctions.

Your provider will carefully use this info and work with you to find the right prescription, which will be sent to you by a licensed Swiss pharmacy.

Let’s proceed to the last round of questions.

Continue

Continue

Please tell us your gender. It's important that you give us the gender, that you were assigned, when you were born. This information is important so that we can find the right treatment for you!

Male

Female

Intersex

We remind you that if your erection lasts 4 hours or longer, you should seek medical advice immediately. Although this is rare, you should seek medical advice immediately to avoid permanent damage.

Also, you should not take a combination of several erectile dysfunction medications. There should be a break of 24 hours between 2 doses (36 hours for Cialis/Tadalafil) to avoid risks. Also, you should not exceed the prescribed dose.

Be aware that it is recommended to have already had experience with Sildenafil or Tadalafil or Viagra or Cialis before trying different strengths.

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