Mens E.D. Score

LETS GET YOUR ERECTILE DYSFUNCTION SCORE

WHAT IS YOUR E.D. SCORE

Health Insurance will not cover Men's E.D. acoustic Wave Care.
Patients will pay out of pocket for Wave Care, by using Health Savings/ FSA,
debt card, Cash and credit card.

* Indicates required field

Do you have a planed budget for covering the cost for E.D. Care? *

Name *

First

Last

Phone Number *

How do you want to be contacted? *

Text Message Call

What is best time to contact you? *

Morning Afternoon Evening

What is your age? *

26-35 36-50 50-60 60+

OVER THE LAST YEAR RATE YOUR SYMPOTMS FROM 1-5 WITH THE NEXT FIVE QUESTIONS.

1. How often were you able to get an erection during sexual activity?

PLEASE SELECT NUMBER THAT BEST RESPRESENTS YOUR ERECTILE SYMPTOM *

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

PLEASE SELECT THE NUMBER THAT BEST REPRESENTS YOUR ERECTILE SYMPTOM *

3. When you attempted intercourse how often where you able to penetrate ( enter) your partner?

PLEASE SELECT THE NUMBER THAT BEST REPRESENTS YOUR ERECTILE SYMPTOM *

4. During sexual intercourse how often were you able to maintain your erection after you had penetrated ( entered ) your partner?

PLEASE SELECT THE NUMBER THAT BEST REPRESENTS YOUR ERECTILE SYMPTOM *

5. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

PLEASE SELECT THE NUMBER THAT BEST REPRESENTS YOUR ERECTILE SYMPTOM *

6. How do you rate your confidence that you could get and keep a erection?

PLEASE SELCET THE NUMBER THAT BEST REPRESENTS YOUR ERECTILE SYMPTOM *

Submit

WHAT IS YOUR E.D. SCORE

5204 South Redwood Road Ste C3​Taylorsville, UT 84123

5204 South Redwood Road Ste C3
Taylorsville, UT 84123