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1
Where did you first hear about Novus?
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Instagram
Facebook
YouTube
TikTok
Google
Word of Mouth
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2
What's your age?
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Less than 40
40-50
50-60
60-70
Over 70
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3
What's your waist size?
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Less than 40 inches
40 inches or more
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4
Q3 lifestyle
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5
How often do you exercise?
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Rarely
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Very Often
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6
Q4 lifestyle
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7
How often do you drink alcohol?
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Never (I don't drink)
Rarely (1-2 drinks per month)
Sometimes (1-2 drinks per week)
Often (3-5 drinks per week)
Very Often (7+ drinks per week)
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8
Q5 lifestyle
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9
How often do you smoke cigarettes?
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Never
Rarely
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Often
Very Often
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10
Q6 lifestyle
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11
How often do you use marijuana?
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Smoking, edibles, etc. Yes, this is important.
Never
Rarely
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Often
Very Often
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12
Q7 lifestyle
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13
Q7 hormone_balancing
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14
Do you have Peyronie's Disease aka Scar Tissue in the shaft? (Did your penis "break" during a sexual accident or physical accident?)
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If you still aren't sure, are your erections painful? Is there an unnatural curve? These are typical signs of Peyronie's Disease.
Yes
No
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15
Q8 peyronies_disease
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16
Are you able to get an erection when using vasodilators?
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(Viagra, Cialis, PDE5i, the "blue pill," etc.)
Yes
No
I don't use the "blue pill"
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17
Q9 micro_plaque
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18
Do you need chemical injections to get or keep an erection?
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(Trimix, Quadmix, etc.)
Yes
No
I don't use chemical injections
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19
How would you rate your confidence that you can get and keep an erection?
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(You're powering through this! Keep going, the more questions you answer, the more personalized your protocol will be.)
Very Low
Low
Moderate
High
Very High
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20
When you have erections with sexual stimulation, how often were your erections hard enough for penetration?
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Never
A Few Times
Sometimes
Most Times
Always
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21
During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?
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Never
A Few Times
Sometimes
Most Times
Always
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22
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
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Extremely Difficult
Very Difficult
Difficult
Slightly Difficult
Not Difficult
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23
When you attempted sexual intercourse, how often was it satisfactory for you?
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Never
A Few Times
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Most Times
Always
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24
Shim_score
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25
Do you ever get morning erections?
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Yes
No
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26
Q16 hormone_balancing
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27
Do you still get spontaneous erections?
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Yes
No
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28
Q17 hormone_balancing
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29
Are you able to get a firm erection during masturbation?
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Yes
No
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30
Q18 psychological
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31
On average, do you get at least 7 hours of sleep per night?
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Yes, this question matters.
Yes
No
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32
Q19 hormone_balancing
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33
Has your ejaculate fluid changed or lessened over time?
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Yes
No
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34
Q20 hormone_balancing
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35
Have you checked your testosterone levels within the past 12 months?
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(Now we're getting specific. The more detail you give us, the more detailed and personalized your protocol will be!)
Yes
No
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36
Was your Total Testosterone over 600?
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Yes
No
I don't know
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37
Q22 hormone_balancing
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38
Was your Free Testosterone and your Estradiol checked?
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Yes
No
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39
Q23 hormone_balancing
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40
During intercourse, do your erections become less firm, or go away entirely, upon switching positions or laying on your back?
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(This is a symptom of "Venous Leak.")
Yes
No
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41
Q24 venous_leak
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42
Do you have a history of varicose veins or hemorrhoids?
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Yes
No
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43
Q25 venous_leak
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44
Can you sustain an erection using a cock ring?
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Yes
No
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45
Are you diabetic?
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Yes
No
I don't know
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46
Q27 diabetes
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47
Is your A1C under 7?
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(The hemoglobin A1c test tells you your average level of blood sugar over the past 2 to 3 months. It's also called HbA1c, glycated hemoglobin test, and glycohemoglobin.)
Yes
No
I don't know
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48
Q28 diabetes
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49
Do you have a history of High Blood Pressure?
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Even if it is better now, please answer Yes if it used to be an issue.
Yes
No
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50
Q29 high_blood_pressure
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51
Is your High Blood Pressure under control?
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(Is your blood pressure less than 130/80?)
Yes
No
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52
Q30 high_blood_pressure
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53
Do you take a Beta Blocker?
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(Metoprolol, Atenolol, anything that ends in -olol, etc.)
Yes
No
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54
Q31 medication
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55
Have you ever had Prostate Cancer?
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Yes
No
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56
Have you ever had any type of prostate surgery or treatment?
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Yes
No
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57
Q33 nerve_damage
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58
Were you able to get full erections BEFORE prostate surgery?
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Yes
No
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59
Were you able to get full erections AFTER prostate surgery?
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Yes
No
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60
Q35 nerve_damage
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61
Have you ever had any spinal injuries?
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Yes
No
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62
Q36 nerve_damage
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63
Do you think your erections have been affected by the spinal injury?
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(Were they stronger BEFORE the injury, and weaker AFTER the injury?)
Yes
No
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64
Q37 nerve_damage
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65
Is your penis less sensitive than it used to be?
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Has your sensation in the penis weakened over time?
Yes
No
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66
Q38 nerve_damage
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67
Do you find it difficult to achieve orgasm?
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Yes
No
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68
Do you experience premature ejaculation?
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(You're almost done with the quiz!)
Yes
No
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69
Q40 nerve_damage
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70
Q40 psychological
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71
Do you wake up more than 2 times per night to urinate?
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(This could indicate prostate-related problems.)
Yes
No
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72
Do you have a history of chronic UTIs or bladder infections?
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Yes
No
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73
Do you ever find yourself worried about getting and keeping an erection for intercourse?
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Yes
No
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74
Q43 psychological
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75
Do you have depression or anxiety?
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Yes
No
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76
Q44 psychological
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77
Are you currently taking any anti-depressants or anti-anxiety medication?
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Yes
No
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78
Q45 psychological
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79
Q45 medication
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80
Are you currently taking any prescription medication on a daily basis?
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Yes
No
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81
Q46 medication
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82
Did you have erection problems BEFORE taking the medication?
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Yes
No
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83
Q47 medication
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84
Did your erections progressively decline after starting medication?
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Yes
No
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85
Q48 medication
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86
What's your primary goal?
Choose as many as you like
Male Enhancement
Treat Erectile Dysfunction
Treat Peyronie's Disease
Other
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87
nerve_damage
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88
diabetes
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89
high_blood_pressure
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90
psychological
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91
venous_leak
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92
micro_plaque
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93
medication
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94
hormone_balancing
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95
peyronies_disease
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96
lifestyle
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97
Max Value
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98
Final Variable
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99
Congratulations, you've completed the quiz! Based on your answers, it appears you may have Nerve Damage-Induced E.D. If you'd like help reversing this problem and improving your sexual performance, what email should we send your Personalized "Nerve-Damage" Protocol to?
*
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We never spam, and will protect your data like we protect our patients.
example@example.com
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100
Congratulations, you've completed the quiz! Based on your answers, it appears you may have Diabetes-Induced E.D. If you'd like help reversing this problem and improving your sexual performance, what email should we send your Personalized "Diabetes" Protocol to?
*
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We never spam, and will protect your data like we protect our patients.
example@example.com
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101
Congratulations, you've completed the quiz! Based on your answers, it appears you may have High Blood Pressure-Induced E.D. If you'd like help reversing this problem and improving your sexual performance, what email should we send your Personalized "High Blood Pressure" Protocol to?
*
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We never spam, and will protect your data like we protect our patients.
example@example.com
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102
Congratulations, you've completed the quiz! Based on your answers, it appears you may have Psychologically-Induced E.D. If you'd like help reversing this problem and improving your sexual performance, what email should we send your Personalized "Psychology" Protocol to?
*
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We never spam, and will protect your data like we protect our patients.
example@example.com
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103
Congratulations, you've completed the quiz! Based on your answers, it appears you may have Venous Leak-Induced E.D. If you'd like help reversing this problem and improving your sexual performance, what email should we send your Personalized "Venous Leak" Protocol to?
*
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We never spam, and will protect your data like we protect our patients.
example@example.com
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104
Congratulations, you've completed the quiz! Based on your answers, it appears you may have Micro-Plaque E.D. If you'd like help reversing this problem and improving your sexual performance, what email should we send your Personalized "Micro-Plaque" Protocol to?
*
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We never spam, and will protect your data like we protect our patients.
example@example.com
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105
Congratulations, you've completed the quiz! Based on your answers, it appears you may have Medication-Induced E.D. If you'd like help reversing this problem and improving your sexual performance, what email should we send your Personalized "Medication" Protocol to?
*
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We never spam, and will protect your data like we protect our patients.
example@example.com
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106
Congratulations, you've completed the quiz! Based on your answers, it appears you may have Hormonal Imbalance-Induced E.D. If you'd like help reversing this problem and improving your sexual performance, what email should we send your Personalized "Hormone Balancing" Protocol to?
*
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We never spam, and will protect your data like we protect our patients.
example@example.com
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107
Congratulations, you've completed the quiz! Based on your answers, it appears you may have Peyronie's Disease. If you'd like help reversing this problem and improving your sexual performance, what email should we send your Personalized "Peyronie's Disease" Protocol to?
*
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We never spam, and will protect your data like we protect our patients.
example@example.com
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108
Congratulations, you've completed the quiz! Based on your answers, it appears you may have Lifestyle-Induced E.D. If you'd like help reversing this problem and improving your sexual performance, what email should we send your Personalized "Lifestyle" Protocol to?
*
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We never spam, and will protect your data like we protect our patients.
example@example.com
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109
Combined Email
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110
60. Your SHIM Score is {shim_score}. That means you have Severe ED. Would you like a telehealth consultation to learn your options for reversing this problem?
Would you like a telehealth consultation to learn your options for reversing this problem?
Yes
No
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111
61. Your SHIM Score is {shim_score}. That means you have Moderate ED. Would you like a telehealth consultation to learn your options for reversing this problem?
Yes
No
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112
62. Your SHIM Score is {shim_score}. That means you have Mild ED. Would you like a telehealth consultation to learn your options for reversing this problem?
Yes
No
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113
63. Your SHIM Score is {shim_score}. That usually means you wouldn't mind an improvement in sexual performance. Would you like a telehealth consultation to learn your options for enhancing your performance even more?
Yes
No
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114
64. You stated you have Peyronie's Disease. Would you like a free phone consultation to learn your options for reversing this problem?
Yes
No
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115
65. We will send you additional information pertaining to your SHIM Score
*
This field is required.
By providing your your phone number you will have direct access to one of our Patient Care Providers.
We respect all HIPPA Privacy Policy and we will NEVER share your info with other parties.
Your privacy is of the upmost importance and we will not blow up your phone. If seeking urgent attention visit our website or give us a call TheNovusCenter.com
Please enter a valid phone number.
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116
66. Please include your name so we know who we're speaking with when we call
Thank you!
First Name
Last Name
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117
67. Are you in the Los Angeles Area? If not would you be willing to Travel for a One Time Treatment?
Our clinic is based in Los Angeles, but we offer some remote options!
Local
Can Travel
Won't Travel
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118
68. Do you already own the Phoenix Shockwave Device?
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Go to www.orderthephoenix.com to learn more
YES
NO
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119
69. What is your zip code?
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e.g. 91602
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