Sexual wellness for men – BodyRejuvenation

Section 1: Personal Information

Personal Information

First

Middle

Last

Section 2: Medical History

Do you currently suffer from any chronic diseases (e.g., diabetes, hypertension, heart diseases)? Please specify.

Yes
No

Please specify

Are you currently taking any medications? Please list them.

Yes
No

Please specify

Have you previously or are you currently receiving any form of sexual wellness treatments?

Yes
No

Please specify

Section 3: Symptoms and Current Concerns

Have you experienced a decrease in libido or sexual desire recently?

Yes
No

Have you had difficulties achieving or maintaining an erection?

Yes
No

On a scale of 1-10, how would you rate your sexual performance?

1 being very poor, 10 being excellent

Are you experiencing any of the following symptoms? (Check all that apply)

Please specify

Section 4: Treatment Preferences

Which of the following treatments would you consider using? (Check all that apply)

Testosterone Replacement Therapy (TRT)
PT-141 peptide
Intracavernous injections with PRP
Intracavernous injections with exosomes

What are your primary goals for seeking treatment? (Check all that apply)

Please specify

Section 5: Lifestyle

Describe your current exercise routine

Describe your diet

Do you use tobacco or alcohol? If so, how frequently?

Never
Occasionally
Regularly

How would you describe your stress levels on a regular basis?

Low
Moderate
High

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

Yes
No

How much do you budget for your wellness each year?

Less 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.

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?

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

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

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

If you live far, we do offer virtual consultations