Confidential ED Quiz
Over the past 6 months . . .
How do you rate your confidence that you could get and keep an erection?
*
Low
Moderate
High
When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
*
No sexual activity
Almost never or never
Sometimes
Almost Always
Always
During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
*
Did not attempt intercourse
Almost never or never
A few times
Sometimes
Most times
Almost always or always
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
*
Did not attempt intercourse
Extremely difficult
Very difficult
Difficult
Slightly difficult
When you attempted sexual intercourse, how often was it satisfactory for you?
*
Did not attempt intercourse
Almost never or never
Sometimes
Most times
Almost always or always
Would you be interested in a confidential phone call to discuss how we can help?
*
Yes
No
If Yes, what is the best day and time to confidentially contact you?
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
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