1234567 Select Your Gender MALE FEMALE Date of Birth Phone State Next How Confident are you in Getting/Keeping an Erection? Not Confident Low Confident Somewhat Confident Mostly Confident Very Confident How often are your erections firm enough for intercourse? Rarely or Never A Few Times Sometimes Most Times Almost Always or Always How difficult is it to keep an erection to the finish of intercourse? Extremely Difficult Very Difficult Somewhat Difficult Slightly Difficult Not Difficult How often are your satisfied when attempting intercourse? Rarely or Never A Few Times Sometimes Most Times Almost Always or Always Is your sexual Performance affected by the following? Check all that apply. A Feeling of Nervousness or anxiety before and/or during sex Concern about your sexual Performance Concern about your body image Concerns about sexual dysfunction conditions you may have Relationship Problems None Have you ever taken ED Medications? YES NO PreviousNext Have you had a physical exam with a healthcare provider in the past 2 years? YES, It was normal. Yes, But there were issues. NO State yout Issues with healthcare exam. PreviousNext Do You ever have any medical Conditions or a history of prior suggestions? YES NO What is you history and what were the conditions? PreviousNext Are you currently on a medication? Vitamins or Dietary Supplements. YES NO Please List all your medications, Vitamins or Supplementary Diets and Thrir dosages PreviousNext Do You have any allergies? YES NO Please List all your allergy Issues PreviousNext Have you ever had any of the following cardiovascular (Heart) issues? Heart Attack, Heart Failure or Narrowing of the Arteries Irregular Heartbeat or Previous Send
