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Please help us help you.
By completing the following questionnaire, you will be providing us with information that will help us to better answer your questions.   

HOWEVER, 

All answers are OPTIONAL, so if they do not apply to you, or if you do not want to complete them,
we would still very much like to be of service to you.  Simply leave those spaces blank and submit your question by clicking the submit button below.

Which items best describe your concern? (You may choose more than one)

      Difficulty getting an erection
Difficulty maintaining an erection
Ejaculating too quickly
Ejaculating too late or not at all
Low sex drive
Other.  Please Specify

Approximately, how long has this been going on?   

       Less than 1 year
  1 - 3 years
  3 – 5 years
  5 – 10 years
  More than 10 years
  Ever since I can remember

When do these problems occur?

          All or most of the time
    Occasionally
    Rarely

During which activities do your problems occur?

           During sexual intercourse (penetration)
     During oral sex (mouth to genital contact)
     During manual stimulation (hand to genital contact with partner)
     During masturbation

In which weight category do you fall?

           Underweight
     Weight is within average/healthy range
     Overweight (waistline is 40" or more)

Have you experienced any of the following?

           Depression
      High stress
     Diabetes
      Other vascular diseases (e.g. Arteriosclerosis)
     Prostate Surgery
      Other surgery in the pelvic area:
     Multiple Sclerosis
      Other neurological disease:
     Brain, spinal chord or pelvic injury
     Heart problems
      High cholesterol and/or Triglyceridemia

Do you engage in any of the following activities on a regular basis?

           Smoking (everyday)
     Drinking Alcohol (approx. 2-3 drinks / day)
     Cycling (5 hours or more per week)

Have you seen a doctor about sexual concerns in the past?    Yes    No 

Which treatments, if any, have you already tried?  

Who initiated your descision to seek treatment?

     Myself
     My partner
     My doctor
   Other:

What is your first language? 

What is your nationality / ethnic background:     

Where did you find our web site address?

 Search engine? Which one? 
 Newspaper? Which one?    
 other? Please describe:        

Relationship/Marital status: (Check one or more): 

        Married  
  Common law  
  Have partner
  Currently single
  Divorced or separated 
  If applicable, was this divorce / separation partially caused by the sexual problems?

If applicable please describe the quality of your relationship:

             Not very good, many problems
       Satisfactory, but could be better
       Very healthy and loving

Is your partner sensitive and supportive of the sexual problems you are experiencing?

          Yes    Sometimes    No

What is your occupation? 

How can we reach others like you?

I read  regularly 
      cultural/community newspaper(s)

I read regularly
                  magazine(s)

I listen to regularly
                        radio station(s)

Other suggestions 

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