ENHANCED WELLNESS LIVING

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First Name *

Last Name *

Date of birth

Phone *

Email *

Height/Weight

Tell us about all past and current medical conditions and allergies. Do you have a history of Diabetes/Hypertension or Cardiovascular Disease? *

What areas of improvement and primary goals are you interested in (Performance, ED, Peyronie’s Disease, etc.)? *

Sexual Health Inventory for Men-Erectile Harness Score-CHOOSE ONE *

Sexual Health Inventory for Men:

Rate your confidence in your ability to achieve and maintain an erection:

1-Very Low

2-Low

3-Moderate

4-High

5-Very High

When you achieve an erection with sexual stimulation, how often are your erections hard enough for penetration?

1-Never

2-Not Often

3-Sometimes

4-Most Times

5-Always

During intercourse, how often are you able to maintain an erection after penetration?

1-Never

2-Not Often

3-Sometimes

4-Most Times

5-Always

During intercourse, how difficult is it to maintain your erection to the completion of intercourse?

1-Not Possible

2-Very Difficult

3-Difficult

4-Slightly Difficult

5-Not Difficult/Easy

When you've attempted sexual intercourse, how often was it satisfactory for you?

1-Never

2-Not Often

3-Sometimes

4-Most Times

5-Always

How did you hear about us? *

ENHANCED WELLNESS LIVING

115 W Jackson Street, Suite 1E · Ridgeland, MS 39157 · 601-364-1132

Kelly Engelmann, FNP-BC · Amanda Carter, FNP-C

ENHANCED WELLNESS LIVING

Book your Free Consultation

Takes about a minute. We'll take you straight to the calendar.

ENHANCED WELLNESS LIVING

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