First Name:*


What is your email address?:*


what is your phone number?:


What is your mobile number?:*


How old are you?:


Are you currently taking any prescription medication?:


If so, what medication and what is it for?:


Do you drink alcohol?:


If so, how many drinks, on average, would you consume per week?:


Do you smoke?:


If so, how many cigarettes per day?:


If so, how much and how often?:


Do you exercise?:


If not, when was the last time you were physically active?:


Are you sexually active?:


If so, how often per week are you active?:


Is this adequate or would you like to be more active?:


If not sexually active, when was the last time you had sexual intercourse?:


Are you happy with your current sexual performance?:


Are you satisfied with the time it takes you to reach climax?:


If not, what is the average time it takes for you to climax?:


How long would you like it to be?:


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


Is your sexual performance affecting your relationship?:


When you get erections, do you feel that they could be harder?:


Do they feel softer than you remember them to be?:


Have you taken any medication before for sexually related issues, such as Viagra or Cialis ?:


If so how often, and when was the last time?:


Did you get the desired result?:


Do you have a lack of energy during the day?:


Do you have a decrease in your sex drive?:


Are you stressed from your current working situation?:


Are you getting enough sleep, ie. 6-8 Hours per day?:






* Required field