Hybrid Pharm ED Medication

Legal Government Name(Required)

First Last

Please place the address you would like your medication delivered too(Required)

Street Address Address Line 2 City Province Postal Code

Medication delivery can be sent anywhere across Canada

Best Contact Phone Number(Required)

Email(Required)

What's your gender(Required)

Male

Female

Transgender/Non-binary

We understand these options aren't comprehensive, but this is for hormonal purposes

Marital Status

Single

Married

Divorced

Widowed

Other

Date of Birth (mm/dd/yyyy)(Required)

What is your weight (lbs) ?(Required)

What is your height ?(Required)

Example: 5 ft 7"

Please upload 2 forms of government issued identification(Required)

Drop files here or

Accepted file types: jpg, jpeg, ldf, gif, png, Max. file size: 80 MB, Max. files: 4.

2 (TWO) Forms of government identification include a driver's license, health card, passport, etc. We do not bill any provincial insurance Full ID documents are required for dispensing of controlled substance medications.

Please upload any past prescription to support your current request

Drop files here or

Accepted file types: pdf, jpeg, jpg, Max. file size: 80 MB, Max. files: 4.

How can we help you today ?(Required)

ED Medication

Other

Please indicate which therapy treatment you were looking to address with our health practitioner.

What brings you in (Select all that applies)(Required)

Decreased libido

Decreased morning erections

Ejaculate too quickly/premature ejaculation

Depression

Sleep Problems

Unusual Sweating

Brain fog

Not able to perform sexually

Briefly tell us a little bit about your health goals(Required)

Please provide as much information as possible to understand your goals, lifestyle and current social environment.

How long have the above symptoms been occurring? (Select one)(Required)

Less than 1 year

Approximately 1 year

2-3 years

4-5 years

> 5 years

Do any of the below improve your symptoms? (Select any that apply)(Required)

Caffeine

Exercise

Sleep

Testosterone

None

Please tell us about any ED medications you have used or are currently using, the doses and how effective they were.

Tell us more about the other symptoms you have been experiencing.(Required)

Please provide as much information for the health practitioner to assess your request

Do you smoke tobacco, vape nicotine, and/or use other tobacco products?(Required)

Yes

What type of tobacco product do you use, how much and how often?

Have you had blood work done to check for diabetes in the last 2 years?(Required)

Yes

What was your most recent blood pressure reading?(Required)

Low - Normal120/80 or lower

Above Normalbetween 121/80 to 129/80

High between 130/81 to 139/89

Higher greater than 140/90

I don't know my blood pressure

Your blood pressure helps us determine if it is safe for you to use certain types of ED medications. We require that you are honest about your blood pressure and that your blood pressure was taken within the last 6 months.

Was your blood work normal?(Required)

Yes

I do not know

Do you use any recreational drugs? Some drugs may cause life-threatening interactions with ED medications.(Required)

Amyl Nitrate or Butyl Nitrate

Cocaine or Crack

Poppers or Rush

Cannabis

Other

None

Select all that apply

Are big life changes or stressors happening to you right now?(Required)

None

Lots of new stress

Some Minor Stress

Not sure

Do any of the following currently apply to you?(Required)

Cancer

Kidney Problems

Liver Problems

Lung or pulmonary problems

Nerve or neurological problems

Using steroids or hormones

None of these apply to me

Select all that apply

Have you ever had any of the following medical conditions?(Required)

Select all that apply

Do you have any allergies(Required)

This information is important. Enter all types of allergies, including skin allergies and reactions.

Do you take any medication, vitamins, herbals, or supplements?(Required)

Please enter all medications you currently take, including any and all medications containing Nitroglycerine as well as vitamins, herbals, and supplements.

Have you had any surgeries or hospitalizations?(Required)

Please enter any and all past surgeries below

Do you have any medical conditions?(Required)

Please enter any and all medical conditions below

PHQ-9- Patient Health Questionnaire

Over the last 2 weeks, on how many days have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

2. Feeling down, depressed or hopeless(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

3. Trouble falling or staying asleep, orsleeping too much(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

4. Feeling tired or having little energy(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

5. Poor appetite or over eating(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

6. Feeling bad about yourself-or that youare a failure or have let yourself or your family down(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

7. Trouble concentrating on things, such asreading the newspaper or watching television(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

8. Moving or speaking so slowly that otherpeople could have noticed, or the opposite-being so fidgety or restless that you have been moving around a lot more than usual(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

9.Thoughts that you would be better offdead, or of hurting yourself(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

If you checked off any problems, how difficulty have these made it for you to do your work, take care of things at home, or get along with other people?(Required)

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

GAD-7 Generalized Anxiety Disorder

Over the last 2 weeks, on how many days have you been bothered by any of the following problems?

1. Feeling nervous, anxious, or on edge(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

2. Not being able to stop or control worrying(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

3. Worrying too much about different things(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

4. Trouble relaxing(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

5. Being so restless that it's hard to sit still(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

6. Becoming easily annoyed or irritable(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

7. Feeling afraid as if something awful might happen(Required)

0 - Not at all

1 - Several Days

2 - More than half the days

3 - Nearly every day

If you checked off any problems, how difficulty have these made it for you to do your work, take care of things at home, or get along with other people?(Required)

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

AMS Questionnaire

Which of the following symptoms apply to you at this time? Please mark the appropriate box for each symptom. For symptoms that do not apply, please mark "none"

Decline in your feeling of general well-being(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

(general state of health, subjective feeling)

Joint pain and muscular ache(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

(lower back pain, joint pain, pain in a limb, general back ache)

Excessive sweating(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

(unexpected/sudden episodes of sweating, hot flashes independent of strain)

Sleep Problems(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

(difficulty in falling asleep, difficulty in sleeping through, waking up early and feeling tired, poor sleep, sleeplessness)

Increased need for sleep, often feeling tired(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

Irritability(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

(feeling aggressive, easily upset about little things, moody) .

Nervousness(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

(inner tension, restlessness, feeling fidgety)

Anxiety(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

(feeling panicky)

Physical exhaustion / lacking vitality(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

(general decrease in performance, reduced activity, lacking interest in leisure activities, feeling of gelling less done, of achieving less, of having to force oneself to undertake activities)

Decrease in muscular strength(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

(feeling of weakness)

Depressive mood(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

(feeling down, sad, on the verge of tears, lack of drive. mood swings. feeling nothing is of any use)

Feeling that you have passed your peak(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

Feeling burnt out, having bit rock-bottom(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

Decrease in beard growth(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

Decrease in ability/frequency to perform sexually(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

Decrease in the number of morning erections(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

Decrease in sexual desire/libido(Required)

1 - None

2 - Mild

3 - Moderate

4 - Severe

5 - Extremley Severe

(lacking pleasure in sex, lacking desire for sexual intercourse)

Internation Index of Erectile Function

These questions ask about the effects that your erection problems have had on your sex life over the last four weeks. Please try to answer the questions as honestly and as clearly as you are able. Your answers will help your doctor to choose the most effective treatment suited to your condition. In answering the questions, the following definitions apply:

How often were you able to get an erection during sexual activity?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

When you had erections with sexual stimulation, how often were your erections hard enough for penetration?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

When you attempted intercourse, how often were you able to penetrate (enter) your partner?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

How many times have you attempted sexual intercourse?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

When you attempted sexual intercourse, how often was it satisfactory for you?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

How much have you enjoyed sexual intercourse?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

When you had sexual stimulation or intercourse, how often did you ejaculate?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

How often have you felt sexual desire?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

How would you rate your level of sexual desire?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

How satisfied have you been with your overall sex life?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

How satisfied have you been with your sexual relationship with your partner?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

How do you rate your confidence that you could get and keep an erection?(Required)

0 - No Sexual Activity

1 - Almost never or never

2 - A few times (less than half the time)

3 - Sometimes (about half the time)

4 -Most times (more than half the time)

5 - Almost always or always

Adult Growth Hormone Deficiency Assessment

Listed below are some statements which people make about themselves. Read the list carefully and put a tick in the box marked YES if the statement applies to you. Tick the box marked NO if it does not apply to you. Please remember to answer every item. If you are not sure whether to answer YES or NO tick whichever answer you think is most true in general

I have to struggle to finish jobs(Required)

Yes

I often feel lonely even when I am with other people.(Required)

Yes

I feel a strong need to sleep during the day(Required)

Yes

I have to read things several times before they sink in.(Required)

Yes

It is difficult for me to make friends.(Required)

Yes

It takes a lot of effort for me to do simple tasks.(Required)

Yes

I have difficulty controlling my emotions.(Required)

Yes

I often lose track of what I want to say.(Required)

Yes

I lack confidence(Required)

Yes

I have to push myself to do things.(Required)

Yes

I feel as if I let people down.(Required)

Yes

I often feel very tense.(Required)

Yes

I find it hard to mix with people.(Required)

Yes

I feel worn out even when I’ve not done anything.(Required)

Yes

There are times when I feel very low.(Required)

Yes

I avoid responsibility if possible.(Required)

Yes

I avoid mixing with people I don’t know well.(Required)

Yes

I feel as if I am a burden to other people.(Required)

Yes

I often forget what people have said to me.(Required)

Yes

I find it difficult to plan ahead.(Required)

Yes

I am easily irritated by other people.(Required)

Yes

I often feel too tired to do the things I ought to do.(Required)

Yes

I have to force myself to do all the things that need doing.(Required)

Yes

I often have to force myself to stay awake.(Required)

Yes

My memory lets me down.(Required)

Yes

Have you got any other major symptoms?(Required)

Yes

If Yes, please describe:

Do you have any questions you would like to ask the healthcare practitioner about testosterone/growth hormone medication ?(Required)

Please type above

Please choose the best option that suits your current situation(Required)

An invoice and Interact E-Transfer request will be sent to the email provided within 2 business days.

Product Name(Required)

Please note all prescriptions will be directly sent to Hybrid Pharm to process and dispense

Total

Medication payment will be requested prior to shipment. Please note all payments will be requested by Interact E-Transfer.

By initializing and / or signing this document, you affirm that all of the information in this Medical Wellness Agreement is true and you agree to all of the ASSESSMENT, MEDICAL HISTORY, AGREEMENTS, ACKNOWLEDGEMENTS, and terms hereof.(Required)

PHQ-9- Patient Health Questionnaire

GAD-7 Generalized Anxiety Disorder

AMS Questionnaire

Internation Index of Erectile Function

Adult Growth Hormone Deficiency Assessment

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