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Specialty:

	Urology		Internal Medicine
	Endocrinology		Cardiology
	Family Practice		Other

Additional Information

How did you
hear about our
products?:

	Physician		Magazine
	Television		Friend
	Pharmacy		Radio
	Newspaper		Diabetic Supply
	Website		Other

What is your
cause of sexual
dysfunction?:

	Diabetes		Heart Disease
	Prostate Surgery		Hypertension
	Vascular Disease		Medication
	Cancer		Peyronie's
	Spinal Cord Injury		Other

Have you experienced
any of these
medical conditions?

Mark all that apply.

	Mobility Issues		Diabetes
	Incontinence		Cancer
	Back/Neck Pain		Obesity
	Heart Disease		Vascular Disease
	Arthritis		Poor Circulation
	Prostate Surgery		High Blood Pressure
	Spinal Cord Injury		Joint Pain/Swelling

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