What should we call you?
First Name
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Last Name
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How old are you?
Age
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How tall are you?
Height
*
How much do you weigh?
Weight (lbs)
*
Right now, how do you feel about your sexual health?
Select one
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Sexual Health Current Status
I’m a rockstar
It could be better
There are noticeable problems
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Do you have any specific concerns?
Select one
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Current Sexual Health Concerns
Trouble getting it up
New curve of bend
Softer than I’d like to be
None of these
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Are you in a relationship?
Select one
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Are you in a relationship?
Single
In a relationship
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Have you noticed a decline in your sexual performance as you’ve gotten older?
Select one
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Noticing decline in your sexual performance
Not yet
Somewhat
Definitely
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From 1 to 5, how do you rate your confidence in your ability to get and keep an erection?
1 = Not being confident ... 5 = Confident
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Overall, how healthy is your diet?
Select one
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Overall, how healthy is your diet?
Very healthy
So-so
Not very healthy
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What's your email?
Enter your email address
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What's your cell phone number?
Enter your cell phone number
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