Are You a Candidate forthe EDGEProcedure™?Complete this questionnaire and our doctor will review your responses and contact you to discuss your potential treatment options. There was an error trying to submit your form. Please try again. 1. Over the last month, how often were you able to get an erection during sexual activity? * No sexual activity (0) Almost always or always (5) Most times (much more than half the time) (4) Sometimes (about half the time) (3) A few times (much less than half the time) (2) Almost never or never (1) This field is required. 2. Over the last month, when you had erections with sexual stimulation, how often were your erections hard enough for penetration? * No sexual activity (0) Almost always or always (5) Most times (much more than half the time) (4) Sometimes (about half the time) (3) A few times (much less than half the time) (2) Almost never or never (1) This field is required. 3. Over the last month, when you attempted intercourse, how often were you able to penetrate your partner? * No sexual activity (0) Almost always or always (5) Most times (much more than half the time) (4) Sometimes (about half the time) (3) A few times (much less than half the time) (2) Almost never or never (1) This field is required. 4. Over the last month, during sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner? * No sexual activity (0) Almost always or always (5) Most times (much more than half the time) (4) Sometimes (about half the time) (3) A few times (much less than half the time) (2) Almost never or never (1) This field is required. 5. Over the last month, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? * No sexual activity (0) Almost always or always (5) Most times (much more than half the time) (4) Sometimes (about half the time) (3) A few times (much less than half the time) (2) Almost never or never (1) This field is required. 6. Over the last month, how do you rate your confidence that you can get and keep your erection? * Very high (5) High (4) Moderate (3) Low (2) Very low (1) This field is required. First name * This field is required. Last name * This field is required. Email * This field is required. Phone Number * This field is required. Please verify that you are not a robot. Submit There was an error trying to submit your form. Please try again.
