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Full Name *

Phone Number *

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Primary reason for exploring *

Tried medications & other ED treatments, but haven’t gotten lasting results

Looking for an ED solution in the midst of other health issues

To restore spontaneity in intimate relationships

Age category *

Under 20

21-30

31-40

41 -50

51 and above

Erectile difficulty frequency

Never

Rarely

Often

All the time

Prefer not to say

Erectile difficulty duration

Less than 1 year

From 1 to 5 years

More than 5 years

Prefer not to say

Previous ED treatments attempted *

Lifestyle changes/home remedies

Oral medications (Viagra™, Cialis™, etc.)

Penile injections

Shockwave therapy

Vacuum erection device

Insertable medications

Penile implant

Haven't tried anything yet

*Choose all that apply

Previous experience with any professionals *

No, this is first time

Talked with doctor

Discussed ED with a urologist

Prefer not to say

Co-existing medical conditions (if any) *

Diabetes

Cardiovascular disease

Peyronie's disease

Other

None

*Choose all that apply

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