Questionnaire

Telemedicine Questionnaire

Step 1 of 3

33%

Patient Name

Full Name (read-only)

Presenting Complaint

Main reason for consultation (what are you seeking treatment for today?)(Required)

Symptom onset date(Required)

MM slash DD slash YYYY

Course of symptoms(Required)

Getting better

Worsening

Unchanged

Severity(Required)

Mild

Moderate

Severe

Associated symptoms(Required)

Care Context (Defensibility)

Are you currently in the care of a medical doctor?(Required)

Yes

Did your doctor recommend you buy and start using the product(s) you purchased today?(Required)

Yes

Past Medical History & Allergies

Chronic conditions (tick all that apply)

Hypertension

Diabetes

Asthma/COPD

Heart disease

Kidney disease

Liver disease

Stroke

Cancer

Thyroid disease

Psychiatric condition

None of the above

Any known allergies?(Required)

Yes

List allergies and reactions

Medication History

Current prescription medications

OTC / supplements / herbal products

Safety Check (Red Flags)

Severe or sudden pain?(Required)

Yes

Difficulty breathing or speaking?(Required)

Yes

Chest pain/pressure in last 24 hours?(Required)

Yes

Fainting or loss of consciousness recently?(Required)

Yes

Coughing or vomiting blood?(Required)

Yes

Sudden weakness or numbness in face/arms/legs?(Required)

Yes

Pregnant or breastfeeding?(Required)

Pregnant

Breastfeeding

Module: PDE5 inhibitors (Sildenafil / Tadalafil)

Do you take nitrates (e.g., GTN spray/tablets) or riociguat?

Yes

History of significant heart disease, recent stroke/MI, or very low blood pressure?

Yes

Severe vision disorders (e.g., retinitis pigmentosa) or sudden vision loss history?

Yes

Most recent blood pressure — systolic (mmHg)

Most recent blood pressure — diastolic (mmHg)

Module: Androgen therapy (Testosterone / DHT)

History of prostate cancer, breast cancer, or unexplained high PSA?

Yes

Severe untreated sleep apnea or previously high hematocrit/hemoglobin?

Yes

Planning fertility / trying to conceive?

Yes

Module: Estrogen therapy (17β-estradiol)

History of blood clots (DVT/PE), thrombophilia, or stroke?

Yes

Migraine with aura, active liver disease, or estrogen-sensitive cancer?

Yes

Smoking and age ≥35?

Yes

Module: Progesterone therapy

Currently pregnant? (confirm)

Yes / Unsure

Allergy to components (e.g., peanut oil) or severe liver disease?

Yes

History of unexplained vaginal bleeding?

Yes

Module: Enclomiphene citrate

History of blood clots (DVT/PE), liver disease, or visual disturbances on SERMs?

Yes

Any current fertility treatment under a specialist?

Yes

Module: Modafinil

History of heart problems (arrhythmia), uncontrolled hypertension, or severe anxiety/psychosis?

Yes

Taking MAO inhibitors or past rash/hypersensitivity to modafinil?

Yes

Pregnant, planning pregnancy, or breastfeeding?

Yes

Module: Dermatology / Aesthetics (tretinoin / minoxidil / testosterone propionate 'anti-aging' cream)

Pregnant or trying to conceive (tretinoin contraindicated)?

Yes

Severe eczema/dermatitis or known allergy to product components?

Yes

Where will you apply it, and any prior reactions?

Module: Cardiovascular (telmisartan / nebivolol / combination / rosuvastatin)

For telmisartan: any pregnancy/breastfeeding? (ARBs contraindicated)

Yes / Unsure

For nebivolol: history of severe asthma/COPD, very slow heart rate, or heart block?

Yes

For rosuvastatin: active liver disease, previous statin intolerance/severe muscle pain?

Yes

Recent BP — systolic (mmHg)

Recent BP — diastolic (mmHg)

Recent lipid labs / liver tests (enter values here or upload labs on the next page)

Module: Metformin

Known kidney problems (eGFR < 45), severe liver disease, or heavy alcohol use?

Yes

Any history of lactic acidosis or severe dehydration?

Yes

Module: Thyroid (T3/T4)

History of heart disease, osteoporosis, or adrenal insufficiency?

Yes

Any recent thyroid labs (TSH, FT4, FT3)?

Yes

If yes, enter values here or upload results or attachments on the next page.

Module: Low-dose Naltrexone (LDN)

Currently taking any opioid pain medications (contraindicated)?

Yes

Active liver disease or hepatitis?

Yes

Optional Attachments

Upload lab results / imaging / previous prescriptions (PDF/JPG/PNG)

Drop files here or

Max. file size: 1 GB, Max. files: 5.

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