Back Back pt-141/oxytocin-6 intake form 1 - Have you experienced a decrease in sexual desire or libido? Yes NoPreviousNext2 - Do you have difficulties achieving or maintaining an erection (for males) or experiencing sexual arousal (for females)? Yes NoPreviousNext3 - Have you noticed a decrease in sexual satisfaction or pleasure? Yes NoPreviousNext4 - Have you ever been diagnosed with any sexual health conditions such as erectile dysfunction, low libido, or female sexual arousal disorder? Yes NoPreviousNext5 - Have you ever had any adverse reactions or allergies to the following medications used for sexual health? PT-141 Passion Plus Tadalafil (Cialis) Sildenafil (Viagra) Oxytocin Other I have never had any adverse reactions or allergies to any sexual health medications.PreviousNext5.1 - What medication did you have a reaction with or are allergic to?PreviousNext6 - Are you currently taking any medications or supplements for sexual health? Yes NoPreviousNext6.1 - What are you currently taking?PreviousNext7 - Have you been diagnosed with any of the following? Heart disease that makes sexual intercourse unsafe Uncontrolled high blood pressure Severe kidney or liver disease History of priapism (male only) Erectile dysfunction (male only) NonePreviousNext8 - Do you take any of the following meds that can cause sexual dysfunction? Antidepressants (tricyclic, ssri, MAOI’s.) Antipsychotics (mellaril, navane, haldol) Antipsychotics (mellaril, navane, haldol) Blood pressure medication (B-clockers, bumex, captopril) Cholesterol medications (fenofibrate, atorvastatin, simavastatin) Naltrexone NonePreviousNext9 - Are you currently under the care of a healthcare provider for any sexual health concerns? Yes NoPreviousNext10 - Are you currently pregnant or breastfeeding? Yes NoPreviousNext11 - Do you smoke or have a history of smoking? Yes NoPreviousNext12 - Do you use recreational drugs? Yes NoPreviousNext12.1 - What drugs do you use? Cocaine Marijuana Methamphetamine OtherPreviousNext12.2 - What other drugs do you use?PreviousNext13 - How much alcohol do you drink? 3+ drinks per day 1-2 drinks per day 3-5 drinks per week 1-2 drinks per week NonePreviousNext14 - Please note that PT-141 should not be taken within 72 hours of using oral erectile dysfunction medications or penile injections to avoid potential interactions. This precaution does not apply to Oxytocin. I understand and will comply with the recommendations. Previous Submit Form
