ED Questionnaire – BodyRejuvenation

Have you been formally diagnosed with Erectile Dysfunction by a healthcare provider?

Yes
No

How long have you been experiencing symptoms of ED?

Les than 6 months
6-12 months
1-2 years
More than 2 years

Have you noticed any improvement in your symptoms with your current treatment?

Significant improvement
Moderate improvement
No improvement
Condition worsened

Briefly describe if you experienced any side effects from your current ED medication?

Have you previously tried any of the following treatments for ED? (Check all that apply)

Intracavernous Injections
Vacuum erection devices
Surgical interventions
Herbal or over-the-counter supplements

Do you smoke or use tobacco products?

Yes
No

Are you comfortable providing recent blood work or participating in a comprehensive health assessment?

Yes
No

In the last 3–6 months, what’s been the most frustrating part about your health, energy, or appearance? Please be as specific as possible

(numbers on the scale, lab results, clothes that don’t fit, comments from others, photos you didn’t like, etc.).

Can you describe a recent moment when this problem really bothered you or got in the way of your life? What happened, and how did it make you feel?

How much do you budget for your wellness each year?

Less than $1000
More than $1000. Less than $10,000
More than $10,000

We know this question may feel personal—but it's important. It helps us prioritize patients who are committed to long-term results, and tailor recommendations that make sense financially and medically.

Enter your zip code

We need to make sure your state allows telehealth.

Name

First

Last

Email

Phone

How did you hear about us?

Please specify

If you heard about us from another source, please specify.

Our clinic is located in Hallandale, Florida, are you nearby?

Yes
I can make it
No, but I'm OK with a virtual consultation