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Penis Enlargement Questionnaire
Home
Penis Enlargement Questionnaire
Penis Enlargement
Step
1
of
17
5%
Name
(Required)
First Name
Family Name
Phone Number
Email
(Required)
How old are you?
Less than 18
18 - 24
25 or more
Are you sexually active?
Yes
No
What is the length of your penis when flaccid (measured from the upper part of the penis base up to the frontmost part of the glans)?
Below 9cm (below 3.5 inches)
9 - 12.5cm (3.5 - 5 inches)
12.6cm or more (more than 5 inches)
What is the length of your penis when erected (measured from the upper part of the penis base up to the frontmost part of the glans)?
Below 10 cm (below 4 inches)
10 – 12.5 cm (4 – 5 inches)
12.6 cm or more
How tall are you? (Ft-Inch / cm)
How much do you weigh? (lb / Kg)
Do you have problem with your sex life? Select as many as applies from the following:
I have difficulty getting or maintaining erections
I feel anxious, sad or shy about the size of my penis
I lack sexual satisfaction due to the size of my penis
I feel/know that I cannot satisfy my sexual partner because of the size of my penis
My partner is not happy with the size of my penis
I don’t like how my penis looks like
Have you ever had any treatment for penis enlargement?
Yes
No
If yes please specify
Traction devices
Vacuum devices
Pills and/or lotions
Jelqing
Fat injection
Biodegradable frame insertion
Ligament release surgery
Liposuction
Filler injection
Other
Please specify
Have you ever had a filler injection for any other procedure?
Yes
No
If yes please specify
Do you have any history of allergic reactions to dermal fillers?
Yes
No
Do you have any other allergies?
Yes
No
Are you circumcised?
Yes
No
Do you have any bleeding disorders?
Yes
No
Are you currently taking blood thinning medications?
Yes
No
If yes please specify
Do you have any autoimmune disease?
Yes
No
If yes please specify
Are you taking any medication for that?
Yes
No
If yes please specify
Are you taking any other medications including OTC, herbal/naturopathic and supplements?
Yes
No
If yes please specify
Add
Remove
Do you have any history of hypertrophic scarring (keloid)?
Yes
No
