Sexual Wellness Test – Men

What is the severity of the symptoms you are experiencing? *012345(5 being most severe)

What is the biggest problem that you're having right now? *Lower libidoPremature or delayed ejaculationTrouble getting or keeping an erectionMore than one

How are these symptoms affecting your life? *It's causing problems in my relationshipIt's ruining my self-confidenceI have stress/anxiety that I didn't have beforeI am worried about my overall healthMore than one

When did you notice symptoms appearing? *0 - 6 months6 months to 2 years2 to 5 yearsMore than 5 years

Are you currently taking any medication? *YesNo

Have you been diagnosed with any of the following conditions? *DiabetesProstate CancerHeart DiseaseMore than oneNone of the above

Why haven't you fixed the problem yet? *I'm too embarrassedI haven't had timeThe solutions I've found are too expensiveMore than one

If we can fit our treatment into your budget, are you ready to start right away? *YesNo

How committed are you to getting this fixed TODAY? *I am very committedI am somewhat committedI am not committed yet

Best time to contact... *MorningAfternoonEvening

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300 S Hyde Park Ave., Suite 210
Tampa, FL 33606

888-8AgeWell

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Mon – Fri: 9am – 5pm
Evening & Weekends Available By Appointment

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