Discovery Call Form

Tester Name *

Section 1: Client Information

0/10 completed ▼

Full Name *

City *

User's occupation *

Corporate Employee Business Owner / Self-employed Freelancer Student Retired Unemployed

User's relationship status *

Married In a relationship Single Divorced / Widowed

Are you currently sexually active (sex with partner)? *

Yes No

Do you have more than one sexual partner currently? *

Yes No

First consultation for this issue? *

Yes (first time seeking treatment) No (has tried treatment before)

What was tried earlier? *

Tablets (oral medication) Gels / Sprays (topical) Ayurvedic / Homeopathy Therapy / Counseling

⚠️ Does user have any of these RIGHT NOW? *

Severe pain in penis/testicles (unbearable, can't touch) Blood in urine or semen Erection lasting more than 4 hours (priapism) None of these symptoms

Section 2: ED/PE Branch

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What is the main issue? *

Erectile Dysfunction (ED) Premature Ejaculation (PE) Both ED and PE Others

ED (Erectile Dysfunction) Questions

Since when are you facing erectile dysfunction? *

Since my first sexual experience (Lifelong) Less than 1 month ago 1-6 months ago 6-12 months ago 1-3 years ago More than 3 years ago

Do you get erections at all? *

Yes No

Does it take a long time to get erections? *

Always Sometimes Rarely

Does it stay hard till penetration or completion? *

Loses hardness before penetration Stays hard till penetration, then loses it Stays hard till completion

Is the erection hard enough for penetration? *

Always Sometimes Rarely Never

Are morning erections regular, occasional, or absent? *

Regular (most mornings) Occasional (sometimes) Absent (rarely or never)

Do you get erections during masturbation or with imagination/fantasies? *

Yes, during both masturbation and imagination Yes, during masturbation only Yes, with imagination/fantasies only No, neither works

PE (Premature Ejaculation) Questions

Since when are you facing premature ejaculation? *

Since my first sexual experience (Lifelong) Less than 1 month ago 1-6 months ago 6-12 months ago 1-3 years ago More than 3 years ago

What is your ejaculation time during sex? *

Before penetration Less than 1 minute after penetration 1-3 minutes after penetration More than 3 minutes

Do you feel the penis tip is very sensitive? *

Yes No

If you masturbate, can you delay or control ejaculation? *

Always Sometimes Rarely I don't masturbate

Do you face this issue with all partners or only some? *

All partners Only some partners

Section 3: Masturbation & Behavioral History

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How do you usually masturbate? *

No masturbation Using hands Rubbing against surface (prone) Both hands and rubbing surface

Is your grip during masturbation normal or tight? *

Normal Tight

How often do you masturbate per week? *

None Less than 3 times per week 3-7 times per week 8 or more times per week

How often do you watch porn? *

None Less than 2 times per week 3-5 times per week Daily or more

Do you feel nervous or anxious before or during sex? *

Very often Sometimes Rarely Not at all

How would you describe your partner's response to this issue? *

Supportive Neutral Non-supportive Unaware (haven't told them)

Section 4: Medical & Lifestyle

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Do you have any chronic medical conditions? *

None Diabetes High Blood Pressure Thyroid disorder Heart disease Depression Other (please specify)

Are you currently taking any medications? *

None Psychiatric medications Blood pressure medications Diabetes medications Blood thinners ⚠️ Other (please specify)

⚠️ BLOOD THINNERS CONTRAINDICATION: Do not offer online treatment. Refer to in-person specialist consultation.

Any surgeries or injuries in the spinal or genital area? *

Yes No

⚠️ Recommend Andrologist for offline consultation for genital or spinal surgery or injury

How often do you drink alcohol? *

No alcohol Once a month or less Once every 2 weeks Once a week 2-3 times per week Daily

Do you smoke? *

No smoking Occasionally (only while drinking or social events) Few times per week Daily

Any other substance being consumed?

How stressed do you feel in your daily life? *

High Medium Low None

How is your sleep quality? *

Good Average Poor

How physically active are you? *

Active Somewhat active Not active

Section 5: Other Information

Optional ▶

Other Information (Optional)

Other Information

Is there anything else the agent or doctor should know? Any symptoms, concerns, or context not covered above.

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Discovery Call Form

Section 1: Client Information

Section 2: ED/PE Branch

ED (Erectile Dysfunction) Questions

PE (Premature Ejaculation) Questions

Section 3: Masturbation & Behavioral History

Section 4: Medical & Lifestyle

Section 5: Other Information

Other Information (Optional)

AI Analysis

🤖 AI Analysis

How it works

Start New Consultation?

Discovery Call Form

Section 1: Client Information

Section 2: ED/PE Branch

ED (Erectile Dysfunction) Questions

PE (Premature Ejaculation) Questions

Section 3: Masturbation & Behavioral History

Section 4: Medical & Lifestyle

Section 5: Other Information

Other Information (Optional)

AI Analysis

🤖 AI Analysis

How it works