Erectile Dysfunction Consultation
Note:ED Consult is subject to a $99 fee
Desired Treament Location
*
Minneapolis
San Antonio
Legal First & Last Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
(Area Code) Phone Number
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ethnicity
*
African American
Asian
Caucasian/White
Hispanic
Middle Eastern
Native American
Height (Feet)
*
Height (Inches)
*
Weight (Pounds)
*
List Any/All Medical History
*
List Any/All Surgical History
*
List Any/All Medications
*
List Prescription & OTC Vitamins/Supplements
List Any Medication Allergies
*
How do you rate your CONFIDENCE that you could get & keep an erection?
*
Please Select
1, Very Low
2, Low
3, Moderate
4, High
5, Very High
When you had erections with sexual stimulation, How OFTEN were your erections hard enough for penetration(entering your partner)?
*
Please Select
0, No Sexual Activity
1, Almost Never
2, A Few Times
3, Sometimes
4, Most Times
5, Almost Always
During sexual intercourse, HOW OFTEN were you able to maintain your erection after you had entered your partner?
*
Please Select
0, Did Not Attempt Intercourse
1, Almost Never
2, A Few Times
3, Sometimes
4, Most Times
5, Almost Always
During sexual intercourse, HOW DIFFICULT was it to maintain your erection to completion of intercourse?
*
Please Select
0, Did Not Attempt Intercourse
1, Extremely Difficult
2, Very Difficult
3, Difficult
4, Slightly Difficult
5, Not Difficult
When you attempted sexual intercourse, HOW OFTEN was it satisfactory for you?
*
Please Select
0, Did Not Attempt Intercourse
1, Almost Never
2, A Few Times
3, Sometimes
4, Most Times
5, Almost Always
Submit
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