Name (Optional)              	 

eMail*                           	

City / State*	          	

Country* 			

Age*                               	

Sex*                               	 Male   Female

Marital Status*                        Select one Single Married Cohabiting Divorced Widowed

Nature of problem*                 Nature of problem Masturbation / self pleasuring Genital concerns Sexually Transmitted Diseases Men's Sexual Health Women's Sexual Health Orgasm Disability, Illness and sex Abuse HIV/AIDS Sexual Pleasure Pregnancy fears Contraception Sexual pain Infertility Sexual orientation Desire problem Erection / arousal problems others

Describe your problem / concern here*

                                              

Duration of the problem*       

Always present? If not, when did it begin?*

Does it occur with every partner or only some (if applicable)?*

What do you think is the cause of the problem *


Who is effected by this?*
 

Taken / taking any medicines for this or other reasons?*
 

Do you or did you have any other health problems? Undergone surgeries?*

Tried any self-help?

I have read and understood the Disclaimer and agree to be bound by the conditions stipulated therein.