Are You Dealing With Erectile Dysfunction?

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YES

NO

Are Any Of The Following True?

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I can't perform like I used to

I have to rely on pills to get an erection

I have circulation issues

I have Peyronie's disease (curved, painful erections)

I just want to please my partner the best I can

How Long Have You Dealt With These Symptoms?

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1-3 Months

3-6 Months

6-12 Months

1+ Years

How Have These Symptoms Affected Your Life?

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I'm less confident initiating sex than I used to

I feel embarrassed by it, even though it's not my fault

I can't be spontaneous with sex anymore

I deal with the side effects of pills

I'm frustrated by the lack of sex this issue causes

What ED Treatments Have You Spent Money On?

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Erection Pills

Testosterone Pills/ Injections

Penis Pump

Other

None

First Name *

Last Name *

Email *

Phone Number *

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