www.climaxclinic.com.au
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Submitted URL: http://climaxclinic.com.au/
Effective URL: https://www.climaxclinic.com.au/
Submission: On October 12 via manual from AU — Scanned from AU
Effective URL: https://www.climaxclinic.com.au/
Submission: On October 12 via manual from AU — Scanned from AU
Form analysis 7 forms found in the DOM
POST /#wpcf7-f707-p944-o1
<form action="/#wpcf7-f707-p944-o1" method="post" class="wpcf7-form" novalidate="novalidate">
<div style="display: none;">
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<p> <span class="wpcf7-form-control-wrap your-fname"><input type="text" name="your-fname" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false"
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<p> <span class="wpcf7-form-control-wrap your-lname"><input type="text" name="your-lname" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-validates-as-required" aria-required="true" aria-invalid="false"
placeholder="Last Name *"></span> </p>
<p> <span class="wpcf7-form-control-wrap your-email"><input type="email" name="your-email" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email" aria-required="true"
aria-invalid="false" placeholder="Email *"></span> </p>
<p> <span class="wpcf7-form-control-wrap phone-no"><input type="tel" name="phone-no" value="" size="40" class="wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel" aria-required="true" aria-invalid="false"
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<p> <span class="wpcf7-form-control-wrap your-query"><input type="text" name="your-query" value="" size="40" class="wpcf7-form-control wpcf7-text" aria-invalid="false" placeholder="Query"></span> </p>
<p><input type="submit" value="Submit" class="wpcf7-form-control wpcf7-submit"><span class="ajax-loader"></span></p>
<div class="clear"> </div>
<input type="hidden" class="wpcf7-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="wpcf7-response-output wpcf7-display-none"></div>
</form>POST /
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_8" id="gform_8" action="/">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform_body">
<div id="gform_page_8_1" class="gform_page">
<div class="gform_page_fields">
<ul id="gform_fields_8" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_4" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you have a problem maintaining an erection strong enough for penetration?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_4">
<li class="gchoice_8_4_0"><input name="input_4" type="radio" value="Always" id="choice_8_4_0"><label for="choice_8_4_0" id="label_8_4_0">Always</label></li>
<li class="gchoice_8_4_1"><input name="input_4" type="radio" value="Sometimes" id="choice_8_4_1"><label for="choice_8_4_1" id="label_8_4_1">Sometimes</label></li>
<li class="gchoice_8_4_2"><input name="input_4" type="radio" value="Never" id="choice_8_4_2"><label for="choice_8_4_2" id="label_8_4_2">Never</label></li>
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</div>
</li>
</ul>
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<div class="gform_page_footer">
<input type="button" id="gform_next_button_8_2" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("2"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("2"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_2" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_2" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_5" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">On a scale of 1 - 10 (with 10 being strong) how strong is your average erection?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_5">
<li class="gchoice_8_5_0"><input name="input_5" type="radio" value="1" id="choice_8_5_0"><label for="choice_8_5_0" id="label_8_5_0">1</label></li>
<li class="gchoice_8_5_1"><input name="input_5" type="radio" value="2" id="choice_8_5_1"><label for="choice_8_5_1" id="label_8_5_1">2</label></li>
<li class="gchoice_8_5_2"><input name="input_5" type="radio" value="3" id="choice_8_5_2"><label for="choice_8_5_2" id="label_8_5_2">3</label></li>
<li class="gchoice_8_5_3"><input name="input_5" type="radio" value="4" id="choice_8_5_3"><label for="choice_8_5_3" id="label_8_5_3">4</label></li>
<li class="gchoice_8_5_4"><input name="input_5" type="radio" value="5" id="choice_8_5_4"><label for="choice_8_5_4" id="label_8_5_4">5</label></li>
<li class="gchoice_8_5_5"><input name="input_5" type="radio" value="6" id="choice_8_5_5"><label for="choice_8_5_5" id="label_8_5_5">6</label></li>
<li class="gchoice_8_5_6"><input name="input_5" type="radio" value="7" id="choice_8_5_6"><label for="choice_8_5_6" id="label_8_5_6">7</label></li>
<li class="gchoice_8_5_7"><input name="input_5" type="radio" value="8" id="choice_8_5_7"><label for="choice_8_5_7" id="label_8_5_7">8</label></li>
<li class="gchoice_8_5_8"><input name="input_5" type="radio" value="9" id="choice_8_5_8"><label for="choice_8_5_8" id="label_8_5_8">9</label></li>
<li class="gchoice_8_5_9"><input name="input_5" type="radio" value="10" id="choice_8_5_9"><label for="choice_8_5_9" id="label_8_5_9">10</label></li>
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</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_8_6" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_8").val("1"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("1"); jQuery("#gform_8").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_8_6"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("3"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("3"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_3" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_3" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_9" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">How many minutes are you currently lasting before ejaculating?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_9">
<li class="gchoice_8_9_0"><input name="input_9" type="radio" value="1" id="choice_8_9_0"><label for="choice_8_9_0" id="label_8_9_0">1</label></li>
<li class="gchoice_8_9_1"><input name="input_9" type="radio" value="2" id="choice_8_9_1"><label for="choice_8_9_1" id="label_8_9_1">2</label></li>
<li class="gchoice_8_9_2"><input name="input_9" type="radio" value="3" id="choice_8_9_2"><label for="choice_8_9_2" id="label_8_9_2">3</label></li>
<li class="gchoice_8_9_3"><input name="input_9" type="radio" value="4" id="choice_8_9_3"><label for="choice_8_9_3" id="label_8_9_3">4</label></li>
<li class="gchoice_8_9_4"><input name="input_9" type="radio" value="5" id="choice_8_9_4"><label for="choice_8_9_4" id="label_8_9_4">5</label></li>
<li class="gchoice_8_9_5"><input name="input_9" type="radio" value="6" id="choice_8_9_5"><label for="choice_8_9_5" id="label_8_9_5">6</label></li>
<li class="gchoice_8_9_6"><input name="input_9" type="radio" value="7" id="choice_8_9_6"><label for="choice_8_9_6" id="label_8_9_6">7</label></li>
<li class="gchoice_8_9_7"><input name="input_9" type="radio" value="8" id="choice_8_9_7"><label for="choice_8_9_7" id="label_8_9_7">8</label></li>
<li class="gchoice_8_9_8"><input name="input_9" type="radio" value="9" id="choice_8_9_8"><label for="choice_8_9_8" id="label_8_9_8">9</label></li>
<li class="gchoice_8_9_9"><input name="input_9" type="radio" value="10" id="choice_8_9_9"><label for="choice_8_9_9" id="label_8_9_9">10</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_8_8" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_8").val("2"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("2"); jQuery("#gform_8").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_8_8"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("4"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("4"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_4" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_4" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_10" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you have a problem maintaining an erection strong enough for penetration?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_10">
<li class="gchoice_8_10_0"><input name="input_10" type="radio" value="Always" id="choice_8_10_0"><label for="choice_8_10_0" id="label_8_10_0">Always</label></li>
<li class="gchoice_8_10_1"><input name="input_10" type="radio" value="Sometimes" id="choice_8_10_1"><label for="choice_8_10_1" id="label_8_10_1">Sometimes</label></li>
<li class="gchoice_8_10_2"><input name="input_10" type="radio" value="Never" id="choice_8_10_2"><label for="choice_8_10_2" id="label_8_10_2">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_8_21" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_8").val("3"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("3"); jQuery("#gform_8").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_8_21"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("5"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("5"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_5" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_5" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_11" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you have diabetes?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_11">
<li class="gchoice_8_11_0"><input name="input_11" type="radio" value="Type 1" id="choice_8_11_0"><label for="choice_8_11_0" id="label_8_11_0">Type 1</label></li>
<li class="gchoice_8_11_1"><input name="input_11" type="radio" value="Type 2" id="choice_8_11_1"><label for="choice_8_11_1" id="label_8_11_1">Type 2</label></li>
<li class="gchoice_8_11_2"><input name="input_11" type="radio" value="No" id="choice_8_11_2"><label for="choice_8_11_2" id="label_8_11_2">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_8_22" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_8").val("4"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("4"); jQuery("#gform_8").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_8_22"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("6"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("6"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_6" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_6" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_12" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you suffer from anxiety and/or depression?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_12">
<li class="gchoice_8_12_0"><input name="input_12" type="radio" value="Anxiety" id="choice_8_12_0"><label for="choice_8_12_0" id="label_8_12_0">Anxiety</label></li>
<li class="gchoice_8_12_1"><input name="input_12" type="radio" value="Depression" id="choice_8_12_1"><label for="choice_8_12_1" id="label_8_12_1">Depression</label></li>
<li class="gchoice_8_12_2"><input name="input_12" type="radio" value="Both" id="choice_8_12_2"><label for="choice_8_12_2" id="label_8_12_2">Both</label></li>
<li class="gchoice_8_12_3"><input name="input_12" type="radio" value="None" id="choice_8_12_3"><label for="choice_8_12_3" id="label_8_12_3">None</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_8_23" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_8").val("5"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("5"); jQuery("#gform_8").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_8_23"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("7"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("7"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_7" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_7" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_13" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Have you tested your testosterone levels?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_13">
<li class="gchoice_8_13_0"><input name="input_13" type="radio" value="Yes, normal levels" id="choice_8_13_0"><label for="choice_8_13_0" id="label_8_13_0">Yes, normal levels</label></li>
<li class="gchoice_8_13_1"><input name="input_13" type="radio" value="Yes, low levels" id="choice_8_13_1"><label for="choice_8_13_1" id="label_8_13_1">Yes, low levels</label></li>
<li class="gchoice_8_13_2"><input name="input_13" type="radio" value="No" id="choice_8_13_2"><label for="choice_8_13_2" id="label_8_13_2">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_8_24" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_8").val("6"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("6"); jQuery("#gform_8").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_8_24"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("8"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("8"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_8" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_8" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_14" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">How do you describe your libido?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_14">
<li class="gchoice_8_14_0"><input name="input_14" type="radio" value="Very Strong" id="choice_8_14_0"><label for="choice_8_14_0" id="label_8_14_0">Very Strong</label></li>
<li class="gchoice_8_14_1"><input name="input_14" type="radio" value="Average" id="choice_8_14_1"><label for="choice_8_14_1" id="label_8_14_1">Average</label></li>
<li class="gchoice_8_14_2"><input name="input_14" type="radio" value="No desire for sex" id="choice_8_14_2"><label for="choice_8_14_2" id="label_8_14_2">No desire for sex</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_8_26" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_8").val("7"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("7"); jQuery("#gform_8").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_8_26"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("9"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("9"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_9" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_9" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_15" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">How do you describe your partners libido?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_15">
<li class="gchoice_8_15_0"><input name="input_15" type="radio" value="Very Strong" id="choice_8_15_0"><label for="choice_8_15_0" id="label_8_15_0">Very Strong</label></li>
<li class="gchoice_8_15_1"><input name="input_15" type="radio" value="Average" id="choice_8_15_1"><label for="choice_8_15_1" id="label_8_15_1">Average</label></li>
<li class="gchoice_8_15_2"><input name="input_15" type="radio" value="No desire for sex" id="choice_8_15_2"><label for="choice_8_15_2" id="label_8_15_2">No desire for sex</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_8_27" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_8").val("8"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("8"); jQuery("#gform_8").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_8_27"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("10"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("10"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_10" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_10" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_16" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you suffering from hair loss?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_16">
<li class="gchoice_8_16_0"><input name="input_16" type="radio" value="Yes" id="choice_8_16_0"><label for="choice_8_16_0" id="label_8_16_0">Yes</label></li>
<li class="gchoice_8_16_1"><input name="input_16" type="radio" value="No" id="choice_8_16_1"><label for="choice_8_16_1" id="label_8_16_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_8_30" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_8").val("9"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("9"); jQuery("#gform_8").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_8_30"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("11"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("11"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_11" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_11" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_17" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you having trouble sleeping?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_17">
<li class="gchoice_8_17_0"><input name="input_17" type="radio" value="Yes" id="choice_8_17_0"><label for="choice_8_17_0" id="label_8_17_0">Yes</label></li>
<li class="gchoice_8_17_1"><input name="input_17" type="radio" value="No" id="choice_8_17_1"><label for="choice_8_17_1" id="label_8_17_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_8_31" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_8").val("10"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("10"); jQuery("#gform_8").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_8_31"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("12"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("12"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_12" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_12" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_18" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you smoke?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_18">
<li class="gchoice_8_18_0"><input name="input_18" type="radio" value="Yes" id="choice_8_18_0"><label for="choice_8_18_0" id="label_8_18_0">Yes</label></li>
<li class="gchoice_8_18_1"><input name="input_18" type="radio" value="Yes, but trying to quit" id="choice_8_18_1"><label for="choice_8_18_1" id="label_8_18_1">Yes, but trying to quit</label></li>
<li class="gchoice_8_18_2"><input name="input_18" type="radio" value="No" id="choice_8_18_2"><label for="choice_8_18_2" id="label_8_18_2">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_8_34" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_8").val("11"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("11"); jQuery("#gform_8").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_8_34"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("13"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("13"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_13" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_13" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_19" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you experiencing unexplained tiredness?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_19">
<li class="gchoice_8_19_0"><input name="input_19" type="radio" value="Yes" id="choice_8_19_0"><label for="choice_8_19_0" id="label_8_19_0">Yes</label></li>
<li class="gchoice_8_19_1"><input name="input_19" type="radio" value="No" id="choice_8_19_1"><label for="choice_8_19_1" id="label_8_19_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_8_42" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_8").val("12"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("12"); jQuery("#gform_8").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_8_42"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("14"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("14"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_14" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_14" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_43" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">State of Territory</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_8_43">
<li class="gchoice_8_43_0"><input name="input_43" type="radio" value="NSW" id="choice_8_43_0"><label for="choice_8_43_0" id="label_8_43_0">NSW</label></li>
<li class="gchoice_8_43_1"><input name="input_43" type="radio" value="QLD" id="choice_8_43_1"><label for="choice_8_43_1" id="label_8_43_1">QLD</label></li>
<li class="gchoice_8_43_2"><input name="input_43" type="radio" value="WA" id="choice_8_43_2"><label for="choice_8_43_2" id="label_8_43_2">WA</label></li>
<li class="gchoice_8_43_3"><input name="input_43" type="radio" value="SA" id="choice_8_43_3"><label for="choice_8_43_3" id="label_8_43_3">SA</label></li>
<li class="gchoice_8_43_4"><input name="input_43" type="radio" value="TAS" id="choice_8_43_4"><label for="choice_8_43_4" id="label_8_43_4">TAS</label></li>
<li class="gchoice_8_43_5"><input name="input_43" type="radio" value="NT" id="choice_8_43_5"><label for="choice_8_43_5" id="label_8_43_5">NT</label></li>
<li class="gchoice_8_43_6"><input name="input_43" type="radio" value="ACT" id="choice_8_43_6"><label for="choice_8_43_6" id="label_8_43_6">ACT</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_8_36" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_8").val("13"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("13"); jQuery("#gform_8").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_8_36"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_8").val("15"); jQuery("#gform_8").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_8").val("15"); jQuery("#gform_8").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_8_15" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_8_15" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_8_41" class="gfield formtitle gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible">
<h3>Based on your answers you may have a sexual health issue. Please enter your details for your customised assessment to be sent discreetly to you via SMS or email.</h3>
</li>
<li id="field_8_37" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_8_37">First Name<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_37" id="input_8_37" type="text" value="" class="medium" placeholder="First Name" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_8_38" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_8_38">Last Name<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_38" id="input_8_38" type="text" value="" class="medium" placeholder="Last Name" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_8_39" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_8_39">Email<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_email">
<input name="input_39" id="input_8_39" type="text" value="" class="medium" placeholder="Email" aria-required="true" aria-invalid="false">
</div>
</li>
<li id="field_8_40" class="gfield gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_8_40">Mobile Number<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_phone"><input name="input_40" id="input_8_40" type="text" value="" class="medium" placeholder="Mobile Number" aria-required="true" aria-invalid="false"></div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label"><input type="submit" id="gform_previous_button_8" class="gform_previous_button button" value="Previous"
onclick="if(window["gf_submitting_8"]){return false;} window["gf_submitting_8"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_8"]){return false;} window["gf_submitting_8"]=true; jQuery("#gform_8").trigger("submit",[true]); }"> <input type="submit"
id="gform_submit_button_8" class="gform_button button" value="Submit" onclick="if(window["gf_submitting_8"]){return false;} window["gf_submitting_8"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_8"]){return false;} window["gf_submitting_8"]=true; jQuery("#gform_8").trigger("submit",[true]); }"> <input type="hidden"
name="gform_ajax" value="form_id=8&title=&description=&tabindex=0">
<input type="hidden" class="gform_hidden" name="is_submit_8" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="8">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_8" value="WyJbXSIsIjFkZTc2MjNhNmU4MWVlODVhNmRlNTE0MWI5ZDRjMGQ5Il0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_8" id="gform_target_page_number_8" value="2">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_8" id="gform_source_page_number_8" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</div>
</div>
<input type="hidden" name="pum_form_popup_id" value="2044">
</form>POST /#gf_5
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_5" id="gform_5" action="/#gf_5">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform_body">
<ul id="gform_fields_5" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_5_1" class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible">
<h2>Request Your Free Consultation</h2>
<p>Fill in the form below and one of our consultants will contact you to book your consultation.</p>
</li>
<li id="field_5_2" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_5_2">Name<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_2" id="input_5_2" type="text" value="" class="medium" placeholder="Name*" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_5_3" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_5_3">Age<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_3" id="input_5_3" type="text" value="" class="medium" placeholder="Age" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_5_4" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_5_4">Phone<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_phone"><input name="input_4" id="input_5_4" type="text" value="" class="medium" placeholder="Phone Number*" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_5_5" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_5_5">Email<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_email">
<input name="input_5" id="input_5_5" type="text" value="" class="medium" placeholder="Email*" aria-required="true" aria-invalid="false">
</div>
</li>
<li id="field_5_6" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_5_6">Nature of Enquiry<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_select">
<div class="selection-box"><select name="input_6" id="input_5_6" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Nature of Enquiry</option>
<option value="Erectile Dysfunction">Erectile Dysfunction</option>
<option value="Premature Ejaculation">Premature Ejaculation</option>
<option value="Low Testosterone">Low Testosterone</option>
</select></div>
</div>
</li>
<li id="field_5_7" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible"><label class="gfield_label" for="input_5_7">Where did you hear about us<span
class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_select">
<div class="selection-box"><select name="input_7" id="input_5_7" class="medium gfield_select" aria-required="true" aria-invalid="false">
<option value="" selected="selected" class="gf_placeholder">Where did you hear about us</option>
<option value="Google">Google</option>
<option value="Facebook">Facebook</option>
<option value="Friend">Friend</option>
<option value="Radio">Radio</option>
<option value="Referred by Friend">Referred by Friend</option>
<option value="Referred by Medical Practitioner">Referred by Medical Practitioner</option>
<option value="TV">TV</option>
<option value="Other">Other</option>
</select></div>
</div>
</li>
</ul>
</div>
<div class="gform_footer top_label"> <input type="submit" id="gform_submit_button_5" class="gform_button button" value="Submit" onclick="if(window["gf_submitting_5"]){return false;} window["gf_submitting_5"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_5"]){return false;} window["gf_submitting_5"]=true; jQuery("#gform_5").trigger("submit",[true]); }"> <input type="hidden" name="gform_ajax"
value="form_id=5&title=&description=&tabindex=0">
<input type="hidden" class="gform_hidden" name="is_submit_5" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="5">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_5" value="WyJbXSIsIjFkZTc2MjNhNmU4MWVlODVhNmRlNTE0MWI5ZDRjMGQ5Il0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_5" id="gform_target_page_number_5" value="0">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_5" id="gform_source_page_number_5" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
<input type="hidden" name="pum_form_popup_id" value="1980">
</form>POST /#gf_4
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_4" id="gform_4" action="/#gf_4">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div id="gf_progressbar_wrapper_4" class="gf_progressbar_wrapper">
<h3 class="gf_progressbar_title">Step 1 of 11 </h3>
<div class="gf_progressbar">
<div class="gf_progressbar_percentage percentbar_blue percentbar_9" style="width:9%;"><span>9%</span></div>
</div>
</div>
<div class="gform_body">
<div id="gform_page_4_1" class="gform_page">
<div class="gform_page_fields">
<ul id="gform_fields_4" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_4_4" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Is your erection strength decreasing?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_4_4">
<li class="gchoice_4_4_0"><input name="input_4" type="radio" value="Yes" checked="checked" id="choice_4_4_0"><label for="choice_4_4_0" id="label_4_4_0">Yes</label></li>
<li class="gchoice_4_4_1"><input name="input_4" type="radio" value="No" id="choice_4_4_1"><label for="choice_4_4_1" id="label_4_4_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_next_button_4_2" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_4").val("2"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("2"); jQuery("#gform_4").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_4_2" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_4_2" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_4_41" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you feel tired all the time?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_4_41">
<li class="gchoice_4_41_0"><input name="input_41" type="radio" value="Yes" checked="checked" id="choice_4_41_0"><label for="choice_4_41_0" id="label_4_41_0">Yes</label></li>
<li class="gchoice_4_41_1"><input name="input_41" type="radio" value="No" id="choice_4_41_1"><label for="choice_4_41_1" id="label_4_41_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_4_6" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_4").val("1"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("1"); jQuery("#gform_4").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_4_6"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_4").val("3"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("3"); jQuery("#gform_4").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_4_3" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_4_3" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_4_42" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">How often do you want to have sex?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_4_42">
<li class="gchoice_4_42_0"><input name="input_42" type="radio" value="Daily" checked="checked" id="choice_4_42_0"><label for="choice_4_42_0" id="label_4_42_0">Daily</label></li>
<li class="gchoice_4_42_1"><input name="input_42" type="radio" value="Monthly" id="choice_4_42_1"><label for="choice_4_42_1" id="label_4_42_1">Monthly</label></li>
<li class="gchoice_4_42_2"><input name="input_42" type="radio" value="Never" id="choice_4_42_2"><label for="choice_4_42_2" id="label_4_42_2">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_4_8" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_4").val("2"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("2"); jQuery("#gform_4").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_4_8"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_4").val("4"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("4"); jQuery("#gform_4").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_4_4" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_4_4" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_4_10" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you experiencing mood swings?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_4_10">
<li class="gchoice_4_10_0"><input name="input_10" type="radio" value="Always" checked="checked" id="choice_4_10_0"><label for="choice_4_10_0" id="label_4_10_0">Always</label></li>
<li class="gchoice_4_10_1"><input name="input_10" type="radio" value="Sometimes" id="choice_4_10_1"><label for="choice_4_10_1" id="label_4_10_1">Sometimes</label></li>
<li class="gchoice_4_10_2"><input name="input_10" type="radio" value="No, mood is stable" id="choice_4_10_2"><label for="choice_4_10_2" id="label_4_10_2">No, mood is stable</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_4_21" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_4").val("3"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("3"); jQuery("#gform_4").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_4_21"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_4").val("5"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("5"); jQuery("#gform_4").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_4_5" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_4_5" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_4_47" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you lack motivation and drive?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_4_47">
<li class="gchoice_4_47_0"><input name="input_47" type="radio" value="Always" checked="checked" id="choice_4_47_0"><label for="choice_4_47_0" id="label_4_47_0">Always</label></li>
<li class="gchoice_4_47_1"><input name="input_47" type="radio" value="Sometimes" id="choice_4_47_1"><label for="choice_4_47_1" id="label_4_47_1">Sometimes</label></li>
<li class="gchoice_4_47_2"><input name="input_47" type="radio" value="Never" id="choice_4_47_2"><label for="choice_4_47_2" id="label_4_47_2">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_4_22" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_4").val("4"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("4"); jQuery("#gform_4").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_4_22"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_4").val("6"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("6"); jQuery("#gform_4").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_4_6" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_4_6" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_4_43" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you have trouble sleeping?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_4_43">
<li class="gchoice_4_43_0"><input name="input_43" type="radio" value="Always" checked="checked" id="choice_4_43_0"><label for="choice_4_43_0" id="label_4_43_0">Always</label></li>
<li class="gchoice_4_43_1"><input name="input_43" type="radio" value="Sometimes" id="choice_4_43_1"><label for="choice_4_43_1" id="label_4_43_1">Sometimes</label></li>
<li class="gchoice_4_43_2"><input name="input_43" type="radio" value="Never" id="choice_4_43_2"><label for="choice_4_43_2" id="label_4_43_2">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_4_23" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_4").val("5"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("5"); jQuery("#gform_4").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_4_23"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_4").val("7"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("7"); jQuery("#gform_4").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_4_7" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_4_7" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_4_48" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you experiencing anxiety and/or depression?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_4_48">
<li class="gchoice_4_48_0"><input name="input_48" type="radio" value="Yes" checked="checked" id="choice_4_48_0"><label for="choice_4_48_0" id="label_4_48_0">Yes</label></li>
<li class="gchoice_4_48_1"><input name="input_48" type="radio" value="Sometimes" id="choice_4_48_1"><label for="choice_4_48_1" id="label_4_48_1">Sometimes</label></li>
<li class="gchoice_4_48_2"><input name="input_48" type="radio" value="Never" id="choice_4_48_2"><label for="choice_4_48_2" id="label_4_48_2">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_4_49" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_4").val("6"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("6"); jQuery("#gform_4").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_4_49"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_4").val("8"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("8"); jQuery("#gform_4").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_4_8" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_4_8" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_4_45" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you putting on weight?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_4_45">
<li class="gchoice_4_45_0"><input name="input_45" type="radio" value="Yes" checked="checked" id="choice_4_45_0"><label for="choice_4_45_0" id="label_4_45_0">Yes</label></li>
<li class="gchoice_4_45_1"><input name="input_45" type="radio" value="No" id="choice_4_45_1"><label for="choice_4_45_1" id="label_4_45_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_4_51" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_4").val("7"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("7"); jQuery("#gform_4").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_4_51"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_4").val("9"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("9"); jQuery("#gform_4").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_4_9" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_4_9" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_4_50" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you experiencing hair loss?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_4_50">
<li class="gchoice_4_50_0"><input name="input_50" type="radio" value="Yes" checked="checked" id="choice_4_50_0"><label for="choice_4_50_0" id="label_4_50_0">Yes</label></li>
<li class="gchoice_4_50_1"><input name="input_50" type="radio" value="No" id="choice_4_50_1"><label for="choice_4_50_1" id="label_4_50_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_4_53" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_4").val("8"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("8"); jQuery("#gform_4").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_4_53"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_4").val("10"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("10"); jQuery("#gform_4").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_4_10" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_4_10" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_4_52" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">State of Territory</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_4_52">
<li class="gchoice_4_52_0"><input name="input_52" type="radio" value="NSW" checked="checked" id="choice_4_52_0"><label for="choice_4_52_0" id="label_4_52_0">NSW</label></li>
<li class="gchoice_4_52_1"><input name="input_52" type="radio" value="QLD" id="choice_4_52_1"><label for="choice_4_52_1" id="label_4_52_1">QLD</label></li>
<li class="gchoice_4_52_2"><input name="input_52" type="radio" value="WA" id="choice_4_52_2"><label for="choice_4_52_2" id="label_4_52_2">WA</label></li>
<li class="gchoice_4_52_3"><input name="input_52" type="radio" value="SA" id="choice_4_52_3"><label for="choice_4_52_3" id="label_4_52_3">SA</label></li>
<li class="gchoice_4_52_4"><input name="input_52" type="radio" value="TAS" id="choice_4_52_4"><label for="choice_4_52_4" id="label_4_52_4">TAS</label></li>
<li class="gchoice_4_52_5"><input name="input_52" type="radio" value="NT" id="choice_4_52_5"><label for="choice_4_52_5" id="label_4_52_5">NT</label></li>
<li class="gchoice_4_52_6"><input name="input_52" type="radio" value="ACT" id="choice_4_52_6"><label for="choice_4_52_6" id="label_4_52_6">ACT</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_4_36" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_4").val("9"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("9"); jQuery("#gform_4").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_4_36"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_4").val("11"); jQuery("#gform_4").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_4").val("11"); jQuery("#gform_4").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_4_11" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_4_11" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_4_46" class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible">Based on your answers you may have a sexual health issue. Please enter your
details for your customised assessment to be sent discreetly to you via SMS or email.</li>
<li id="field_4_37" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_4_37">First Name<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_37" id="input_4_37" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_4_38" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_4_38">Last Name<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_38" id="input_4_38" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_4_39" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_4_39">Email<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_email">
<input name="input_39" id="input_4_39" type="text" value="" class="medium" aria-required="true" aria-invalid="false">
</div>
</li>
<li id="field_4_40" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_4_40">Mobile Number<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_phone"><input name="input_40" id="input_4_40" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label"><input type="submit" id="gform_previous_button_4" class="gform_previous_button button" value="Previous"
onclick="if(window["gf_submitting_4"]){return false;} window["gf_submitting_4"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_4"]){return false;} window["gf_submitting_4"]=true; jQuery("#gform_4").trigger("submit",[true]); }"> <input type="submit"
id="gform_submit_button_4" class="gform_button button" value="Submit" onclick="if(window["gf_submitting_4"]){return false;} window["gf_submitting_4"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_4"]){return false;} window["gf_submitting_4"]=true; jQuery("#gform_4").trigger("submit",[true]); }"> <input type="hidden"
name="gform_ajax" value="form_id=4&title=&description=&tabindex=0">
<input type="hidden" class="gform_hidden" name="is_submit_4" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="4">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_4" value="WyJbXSIsIjFkZTc2MjNhNmU4MWVlODVhNmRlNTE0MWI5ZDRjMGQ5Il0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_4" id="gform_target_page_number_4" value="2">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_4" id="gform_source_page_number_4" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</div>
</div>
<input type="hidden" name="pum_form_popup_id" value="1776">
</form>POST /#gf_3
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_3" id="gform_3" action="/#gf_3">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div id="gf_progressbar_wrapper_3" class="gf_progressbar_wrapper">
<h3 class="gf_progressbar_title">Step 1 of 9 </h3>
<div class="gf_progressbar">
<div class="gf_progressbar_percentage percentbar_blue percentbar_11" style="width:11%;"><span>11%</span></div>
</div>
</div>
<div class="gform_body">
<div id="gform_page_3_1" class="gform_page">
<div class="gform_page_fields">
<ul id="gform_fields_3" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_3_4" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you able to control your ejacluation?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_3_4">
<li class="gchoice_3_4_0"><input name="input_4" type="radio" value="Always" checked="checked" id="choice_3_4_0"><label for="choice_3_4_0" id="label_3_4_0">Always</label></li>
<li class="gchoice_3_4_1"><input name="input_4" type="radio" value="Sometimes" id="choice_3_4_1"><label for="choice_3_4_1" id="label_3_4_1">Sometimes</label></li>
<li class="gchoice_3_4_2"><input name="input_4" type="radio" value="Never" id="choice_3_4_2"><label for="choice_3_4_2" id="label_3_4_2">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_next_button_3_2" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_3").val("2"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("2"); jQuery("#gform_3").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_3_2" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_3_2" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_3_41" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you able to satisfy your partner?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_3_41">
<li class="gchoice_3_41_0"><input name="input_41" type="radio" value="Always" checked="checked" id="choice_3_41_0"><label for="choice_3_41_0" id="label_3_41_0">Always</label></li>
<li class="gchoice_3_41_1"><input name="input_41" type="radio" value="Sometimes" id="choice_3_41_1"><label for="choice_3_41_1" id="label_3_41_1">Sometimes</label></li>
<li class="gchoice_3_41_2"><input name="input_41" type="radio" value="Never" id="choice_3_41_2"><label for="choice_3_41_2" id="label_3_41_2">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_3_6" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_3").val("1"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("1"); jQuery("#gform_3").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_3_6"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_3").val("3"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("3"); jQuery("#gform_3").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_3_3" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_3_3" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_3_42" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">How long are you currently lasting during intercourse?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_3_42">
<li class="gchoice_3_42_0"><input name="input_42" type="radio" value="<1 minute" checked="checked" id="choice_3_42_0"><label for="choice_3_42_0" id="label_3_42_0"><1 minute</label></li>
<li class="gchoice_3_42_1"><input name="input_42" type="radio" value="< 2- 4 minute" id="choice_3_42_1"><label for="choice_3_42_1" id="label_3_42_1">< 2- 4 minute</label></li>
<li class="gchoice_3_42_2"><input name="input_42" type="radio" value="5+ minutes" id="choice_3_42_2"><label for="choice_3_42_2" id="label_3_42_2">5+ minutes</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_3_8" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_3").val("2"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("2"); jQuery("#gform_3").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_3_8"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_3").val("4"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("4"); jQuery("#gform_3").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_3_4" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_3_4" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_3_10" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you satisfied with the length it takes you to ejaculate?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_3_10">
<li class="gchoice_3_10_0"><input name="input_10" type="radio" value="Yes" checked="checked" id="choice_3_10_0"><label for="choice_3_10_0" id="label_3_10_0">Yes</label></li>
<li class="gchoice_3_10_1"><input name="input_10" type="radio" value="No" id="choice_3_10_1"><label for="choice_3_10_1" id="label_3_10_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_3_21" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_3").val("3"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("3"); jQuery("#gform_3").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_3_21"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_3").val("5"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("5"); jQuery("#gform_3").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_3_5" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_3_5" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_3_11" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you satisfied with the length it takes you to ejacuate?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_3_11">
<li class="gchoice_3_11_0"><input name="input_11" type="radio" value="Yes" id="choice_3_11_0"><label for="choice_3_11_0" id="label_3_11_0">Yes</label></li>
<li class="gchoice_3_11_1"><input name="input_11" type="radio" value="No" checked="checked" id="choice_3_11_1"><label for="choice_3_11_1" id="label_3_11_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_3_22" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_3").val("4"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("4"); jQuery("#gform_3").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_3_22"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_3").val("6"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("6"); jQuery("#gform_3").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_3_6" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_3_6" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_3_43" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you avoid sex for fear of embarrassment and disappointment?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_3_43">
<li class="gchoice_3_43_0"><input name="input_43" type="radio" value="Always" checked="checked" id="choice_3_43_0"><label for="choice_3_43_0" id="label_3_43_0">Always</label></li>
<li class="gchoice_3_43_1"><input name="input_43" type="radio" value="Sometimes" id="choice_3_43_1"><label for="choice_3_43_1" id="label_3_43_1">Sometimes</label></li>
<li class="gchoice_3_43_2"><input name="input_43" type="radio" value="Never" id="choice_3_43_2"><label for="choice_3_43_2" id="label_3_43_2">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_3_23" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_3").val("5"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("5"); jQuery("#gform_3").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_3_23"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_3").val("7"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("7"); jQuery("#gform_3").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_3_7" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_3_7" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_3_45" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Is it getting worst with time?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_3_45">
<li class="gchoice_3_45_0"><input name="input_45" type="radio" value="Yes" checked="checked" id="choice_3_45_0"><label for="choice_3_45_0" id="label_3_45_0">Yes</label></li>
<li class="gchoice_3_45_1"><input name="input_45" type="radio" value="No" id="choice_3_45_1"><label for="choice_3_45_1" id="label_3_45_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_3_36" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_3").val("6"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("6"); jQuery("#gform_3").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_3_36"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_3").val("8"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("8"); jQuery("#gform_3").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_3_8" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_3_8" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_3_47" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">State of Territory</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_3_47">
<li class="gchoice_3_47_0"><input name="input_47" type="radio" value="NSW" checked="checked" id="choice_3_47_0"><label for="choice_3_47_0" id="label_3_47_0">NSW</label></li>
<li class="gchoice_3_47_1"><input name="input_47" type="radio" value="QLD" id="choice_3_47_1"><label for="choice_3_47_1" id="label_3_47_1">QLD</label></li>
<li class="gchoice_3_47_2"><input name="input_47" type="radio" value="WA" id="choice_3_47_2"><label for="choice_3_47_2" id="label_3_47_2">WA</label></li>
<li class="gchoice_3_47_3"><input name="input_47" type="radio" value="SA" id="choice_3_47_3"><label for="choice_3_47_3" id="label_3_47_3">SA</label></li>
<li class="gchoice_3_47_4"><input name="input_47" type="radio" value="TAS" id="choice_3_47_4"><label for="choice_3_47_4" id="label_3_47_4">TAS</label></li>
<li class="gchoice_3_47_5"><input name="input_47" type="radio" value="NT" id="choice_3_47_5"><label for="choice_3_47_5" id="label_3_47_5">NT</label></li>
<li class="gchoice_3_47_6"><input name="input_47" type="radio" value="ACT" id="choice_3_47_6"><label for="choice_3_47_6" id="label_3_47_6">ACT</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_3_48" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_3").val("7"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("7"); jQuery("#gform_3").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_3_48"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_3").val("9"); jQuery("#gform_3").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_3").val("9"); jQuery("#gform_3").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_3_9" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_3_9" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_3_46" class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible">Based on your answers you may have a sexual health issue. Please enter your
details for your customised assessment to be sent discreetly to you via SMS or email.</li>
<li id="field_3_37" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_3_37">First Name<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_37" id="input_3_37" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_3_38" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_3_38">Last Name<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_38" id="input_3_38" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_3_39" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_3_39">Email<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_email">
<input name="input_39" id="input_3_39" type="text" value="" class="medium" aria-required="true" aria-invalid="false">
</div>
</li>
<li id="field_3_40" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_3_40">Mobile Number<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_phone"><input name="input_40" id="input_3_40" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label"><input type="submit" id="gform_previous_button_3" class="gform_previous_button button" value="Previous"
onclick="if(window["gf_submitting_3"]){return false;} window["gf_submitting_3"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_3"]){return false;} window["gf_submitting_3"]=true; jQuery("#gform_3").trigger("submit",[true]); }"> <input type="submit"
id="gform_submit_button_3" class="gform_button button" value="Submit" onclick="if(window["gf_submitting_3"]){return false;} window["gf_submitting_3"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_3"]){return false;} window["gf_submitting_3"]=true; jQuery("#gform_3").trigger("submit",[true]); }"> <input type="hidden"
name="gform_ajax" value="form_id=3&title=&description=&tabindex=0">
<input type="hidden" class="gform_hidden" name="is_submit_3" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="3">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_3" value="WyJbXSIsIjFkZTc2MjNhNmU4MWVlODVhNmRlNTE0MWI5ZDRjMGQ5Il0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_3" id="gform_target_page_number_3" value="2">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_3" id="gform_source_page_number_3" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</div>
</div>
<input type="hidden" name="pum_form_popup_id" value="1774">
</form>POST /#gf_2
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_2" id="gform_2" action="/#gf_2">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div id="gf_progressbar_wrapper_2" class="gf_progressbar_wrapper">
<h3 class="gf_progressbar_title">Step 1 of 9 </h3>
<div class="gf_progressbar">
<div class="gf_progressbar_percentage percentbar_blue percentbar_11" style="width:11%;"><span>11%</span></div>
</div>
</div>
<div class="gform_body">
<div id="gform_page_2_1" class="gform_page">
<div class="gform_page_fields">
<ul id="gform_fields_2" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_2_4" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">How often can you get an erection?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_2_4">
<li class="gchoice_2_4_0"><input name="input_4" type="radio" value="Always" id="choice_2_4_0"><label for="choice_2_4_0" id="label_2_4_0">Always</label></li>
<li class="gchoice_2_4_1"><input name="input_4" type="radio" value="Sometimes" id="choice_2_4_1"><label for="choice_2_4_1" id="label_2_4_1">Sometimes</label></li>
<li class="gchoice_2_4_2"><input name="input_4" type="radio" value="Rarely" checked="checked" id="choice_2_4_2"><label for="choice_2_4_2" id="label_2_4_2">Rarely</label></li>
<li class="gchoice_2_4_3"><input name="input_4" type="radio" value="Never" id="choice_2_4_3"><label for="choice_2_4_3" id="label_2_4_3">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_next_button_2_2" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_2").val("2"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("2"); jQuery("#gform_2").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_2_2" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_2_2" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_2_41" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Is your erection firm enough to have sex?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_2_41">
<li class="gchoice_2_41_0"><input name="input_41" type="radio" value="Always" id="choice_2_41_0"><label for="choice_2_41_0" id="label_2_41_0">Always</label></li>
<li class="gchoice_2_41_1"><input name="input_41" type="radio" value="Sometimes" id="choice_2_41_1"><label for="choice_2_41_1" id="label_2_41_1">Sometimes</label></li>
<li class="gchoice_2_41_2"><input name="input_41" type="radio" value="Rarely" checked="checked" id="choice_2_41_2"><label for="choice_2_41_2" id="label_2_41_2">Rarely</label></li>
<li class="gchoice_2_41_3"><input name="input_41" type="radio" value="Never" id="choice_2_41_3"><label for="choice_2_41_3" id="label_2_41_3">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_2_6" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_2").val("1"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("1"); jQuery("#gform_2").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_2_6"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_2").val("3"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("3"); jQuery("#gform_2").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_2_3" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_2_3" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_2_42" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Once an erection is gained, can you keep it during sex?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_2_42">
<li class="gchoice_2_42_0"><input name="input_42" type="radio" value="Always" id="choice_2_42_0"><label for="choice_2_42_0" id="label_2_42_0">Always</label></li>
<li class="gchoice_2_42_1"><input name="input_42" type="radio" value="Sometimes" id="choice_2_42_1"><label for="choice_2_42_1" id="label_2_42_1">Sometimes</label></li>
<li class="gchoice_2_42_2"><input name="input_42" type="radio" value="Rarely" checked="checked" id="choice_2_42_2"><label for="choice_2_42_2" id="label_2_42_2">Rarely</label></li>
<li class="gchoice_2_42_3"><input name="input_42" type="radio" value="Never" id="choice_2_42_3"><label for="choice_2_42_3" id="label_2_42_3">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_2_8" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_2").val("2"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("2"); jQuery("#gform_2").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_2_8"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_2").val("4"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("4"); jQuery("#gform_2").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_2_4" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_2_4" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_2_10" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">If you lose the erection, can you get it back?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_2_10">
<li class="gchoice_2_10_0"><input name="input_10" type="radio" value="Always" id="choice_2_10_0"><label for="choice_2_10_0" id="label_2_10_0">Always</label></li>
<li class="gchoice_2_10_1"><input name="input_10" type="radio" value="Sometimes" id="choice_2_10_1"><label for="choice_2_10_1" id="label_2_10_1">Sometimes</label></li>
<li class="gchoice_2_10_2"><input name="input_10" type="radio" value="Rarely" checked="checked" id="choice_2_10_2"><label for="choice_2_10_2" id="label_2_10_2">Rarely</label></li>
<li class="gchoice_2_10_3"><input name="input_10" type="radio" value="Never" id="choice_2_10_3"><label for="choice_2_10_3" id="label_2_10_3">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_2_21" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_2").val("3"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("3"); jQuery("#gform_2").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_2_21"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_2").val("5"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("5"); jQuery("#gform_2").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_2_5" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_2_5" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_2_11" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you satisfied with the length it takes you to ejacuate?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_2_11">
<li class="gchoice_2_11_0"><input name="input_11" type="radio" value="Yes" id="choice_2_11_0"><label for="choice_2_11_0" id="label_2_11_0">Yes</label></li>
<li class="gchoice_2_11_1"><input name="input_11" type="radio" value="No" checked="checked" id="choice_2_11_1"><label for="choice_2_11_1" id="label_2_11_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_2_22" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_2").val("4"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("4"); jQuery("#gform_2").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_2_22"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_2").val("6"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("6"); jQuery("#gform_2").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_2_6" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_2_6" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_2_43" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you able to control your ejacuation?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_2_43">
<li class="gchoice_2_43_0"><input name="input_43" type="radio" value="Always" id="choice_2_43_0"><label for="choice_2_43_0" id="label_2_43_0">Always</label></li>
<li class="gchoice_2_43_1"><input name="input_43" type="radio" value="Sometimes" id="choice_2_43_1"><label for="choice_2_43_1" id="label_2_43_1">Sometimes</label></li>
<li class="gchoice_2_43_2"><input name="input_43" type="radio" value="Never" checked="checked" id="choice_2_43_2"><label for="choice_2_43_2" id="label_2_43_2">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_2_23" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_2").val("5"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("5"); jQuery("#gform_2").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_2_23"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_2").val("7"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("7"); jQuery("#gform_2").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_2_7" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_2_7" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_2_45" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you able to satisfy your partner?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_2_45">
<li class="gchoice_2_45_0"><input name="input_45" type="radio" value="Always" id="choice_2_45_0"><label for="choice_2_45_0" id="label_2_45_0">Always</label></li>
<li class="gchoice_2_45_1"><input name="input_45" type="radio" value="Sometimes" checked="checked" id="choice_2_45_1"><label for="choice_2_45_1" id="label_2_45_1">Sometimes</label></li>
<li class="gchoice_2_45_2"><input name="input_45" type="radio" value="Never" id="choice_2_45_2"><label for="choice_2_45_2" id="label_2_45_2">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_2_36" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_2").val("6"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("6"); jQuery("#gform_2").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_2_36"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_2").val("8"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("8"); jQuery("#gform_2").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_2_8" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_2_8" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_2_47" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">State of Territory</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_2_47">
<li class="gchoice_2_47_0"><input name="input_47" type="radio" value="NSW" id="choice_2_47_0"><label for="choice_2_47_0" id="label_2_47_0">NSW</label></li>
<li class="gchoice_2_47_1"><input name="input_47" type="radio" value="QLD" checked="checked" id="choice_2_47_1"><label for="choice_2_47_1" id="label_2_47_1">QLD</label></li>
<li class="gchoice_2_47_2"><input name="input_47" type="radio" value="WA" id="choice_2_47_2"><label for="choice_2_47_2" id="label_2_47_2">WA</label></li>
<li class="gchoice_2_47_3"><input name="input_47" type="radio" value="SA" id="choice_2_47_3"><label for="choice_2_47_3" id="label_2_47_3">SA</label></li>
<li class="gchoice_2_47_4"><input name="input_47" type="radio" value="TAS" id="choice_2_47_4"><label for="choice_2_47_4" id="label_2_47_4">TAS</label></li>
<li class="gchoice_2_47_5"><input name="input_47" type="radio" value="NT" id="choice_2_47_5"><label for="choice_2_47_5" id="label_2_47_5">NT</label></li>
<li class="gchoice_2_47_6"><input name="input_47" type="radio" value="ACT" id="choice_2_47_6"><label for="choice_2_47_6" id="label_2_47_6">ACT</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_2_48" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_2").val("7"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("7"); jQuery("#gform_2").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_2_48"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_2").val("9"); jQuery("#gform_2").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_2").val("9"); jQuery("#gform_2").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_2_9" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_2_9" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_2_46" class="gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible">Based on your answers you may have a sexual health issue. Please enter your
details for your customised assessment to be sent discreetly to you via SMS or email.</li>
<li id="field_2_37" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_37">First Name<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_37" id="input_2_37" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_2_38" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_38">Last Name<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_38" id="input_2_38" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_2_39" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_39">Email<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_email">
<input name="input_39" id="input_2_39" type="text" value="" class="medium" aria-required="true" aria-invalid="false">
</div>
</li>
<li id="field_2_40" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_2_40">Mobile Number<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_phone"><input name="input_40" id="input_2_40" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label"><input type="submit" id="gform_previous_button_2" class="gform_previous_button button" value="Previous"
onclick="if(window["gf_submitting_2"]){return false;} window["gf_submitting_2"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_2"]){return false;} window["gf_submitting_2"]=true; jQuery("#gform_2").trigger("submit",[true]); }"> <input type="submit"
id="gform_submit_button_2" class="gform_button button" value="Submit" onclick="if(window["gf_submitting_2"]){return false;} window["gf_submitting_2"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_2"]){return false;} window["gf_submitting_2"]=true; jQuery("#gform_2").trigger("submit",[true]); }"> <input type="hidden"
name="gform_ajax" value="form_id=2&title=&description=&tabindex=0">
<input type="hidden" class="gform_hidden" name="is_submit_2" value="1">
<input type="hidden" class="gform_hidden" name="gform_submit" value="2">
<input type="hidden" class="gform_hidden" name="gform_unique_id" value="">
<input type="hidden" class="gform_hidden" name="state_2" value="WyJbXSIsIjFkZTc2MjNhNmU4MWVlODVhNmRlNTE0MWI5ZDRjMGQ5Il0=">
<input type="hidden" class="gform_hidden" name="gform_target_page_number_2" id="gform_target_page_number_2" value="2">
<input type="hidden" class="gform_hidden" name="gform_source_page_number_2" id="gform_source_page_number_2" value="1">
<input type="hidden" name="gform_field_values" value="">
</div>
</div>
</div>
<input type="hidden" name="pum_form_popup_id" value="1772">
</form>POST /#gf_1
<form method="post" enctype="multipart/form-data" target="gform_ajax_frame_1" id="gform_1" action="/#gf_1">
<input type="hidden" class="gforms-pum" value="{"closepopup":false,"closedelay":0,"openpopup":false,"openpopup_id":0}">
<div class="gform_body">
<div id="gform_page_1_1" class="gform_page">
<div class="gform_page_fields">
<ul id="gform_fields_1" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_4" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you have a problem maintaining an erection strong enough for penetration?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_4">
<li class="gchoice_1_4_0"><input name="input_4" type="radio" value="Always" checked="checked" id="choice_1_4_0"><label for="choice_1_4_0" id="label_1_4_0">Always</label></li>
<li class="gchoice_1_4_1"><input name="input_4" type="radio" value="Sometimes" id="choice_1_4_1"><label for="choice_1_4_1" id="label_1_4_1">Sometimes</label></li>
<li class="gchoice_1_4_2"><input name="input_4" type="radio" value="Never" id="choice_1_4_2"><label for="choice_1_4_2" id="label_1_4_2">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_next_button_1_2" class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_2" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_2" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_5" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">On a scale of 1 - 10 (with 10 being strong) how strong is your average erection?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_5">
<li class="gchoice_1_5_0"><input name="input_5" type="radio" value="1" checked="checked" id="choice_1_5_0"><label for="choice_1_5_0" id="label_1_5_0">1</label></li>
<li class="gchoice_1_5_1"><input name="input_5" type="radio" value="2" id="choice_1_5_1"><label for="choice_1_5_1" id="label_1_5_1">2</label></li>
<li class="gchoice_1_5_2"><input name="input_5" type="radio" value="3" id="choice_1_5_2"><label for="choice_1_5_2" id="label_1_5_2">3</label></li>
<li class="gchoice_1_5_3"><input name="input_5" type="radio" value="4" id="choice_1_5_3"><label for="choice_1_5_3" id="label_1_5_3">4</label></li>
<li class="gchoice_1_5_4"><input name="input_5" type="radio" value="5" id="choice_1_5_4"><label for="choice_1_5_4" id="label_1_5_4">5</label></li>
<li class="gchoice_1_5_5"><input name="input_5" type="radio" value="6" id="choice_1_5_5"><label for="choice_1_5_5" id="label_1_5_5">6</label></li>
<li class="gchoice_1_5_6"><input name="input_5" type="radio" value="7" id="choice_1_5_6"><label for="choice_1_5_6" id="label_1_5_6">7</label></li>
<li class="gchoice_1_5_7"><input name="input_5" type="radio" value="8" id="choice_1_5_7"><label for="choice_1_5_7" id="label_1_5_7">8</label></li>
<li class="gchoice_1_5_8"><input name="input_5" type="radio" value="9" id="choice_1_5_8"><label for="choice_1_5_8" id="label_1_5_8">9</label></li>
<li class="gchoice_1_5_9"><input name="input_5" type="radio" value="10" id="choice_1_5_9"><label for="choice_1_5_9" id="label_1_5_9">10</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_6" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("1"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("1"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_6"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("3"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("3"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_3" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_3" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_9" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">How many minutes are you currently lasting before ejaculating?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_9">
<li class="gchoice_1_9_0"><input name="input_9" type="radio" value="1" checked="checked" id="choice_1_9_0"><label for="choice_1_9_0" id="label_1_9_0">1</label></li>
<li class="gchoice_1_9_1"><input name="input_9" type="radio" value="2" id="choice_1_9_1"><label for="choice_1_9_1" id="label_1_9_1">2</label></li>
<li class="gchoice_1_9_2"><input name="input_9" type="radio" value="3" id="choice_1_9_2"><label for="choice_1_9_2" id="label_1_9_2">3</label></li>
<li class="gchoice_1_9_3"><input name="input_9" type="radio" value="4" id="choice_1_9_3"><label for="choice_1_9_3" id="label_1_9_3">4</label></li>
<li class="gchoice_1_9_4"><input name="input_9" type="radio" value="5" id="choice_1_9_4"><label for="choice_1_9_4" id="label_1_9_4">5</label></li>
<li class="gchoice_1_9_5"><input name="input_9" type="radio" value="6" id="choice_1_9_5"><label for="choice_1_9_5" id="label_1_9_5">6</label></li>
<li class="gchoice_1_9_6"><input name="input_9" type="radio" value="7" id="choice_1_9_6"><label for="choice_1_9_6" id="label_1_9_6">7</label></li>
<li class="gchoice_1_9_7"><input name="input_9" type="radio" value="8" id="choice_1_9_7"><label for="choice_1_9_7" id="label_1_9_7">8</label></li>
<li class="gchoice_1_9_8"><input name="input_9" type="radio" value="9" id="choice_1_9_8"><label for="choice_1_9_8" id="label_1_9_8">9</label></li>
<li class="gchoice_1_9_9"><input name="input_9" type="radio" value="10" id="choice_1_9_9"><label for="choice_1_9_9" id="label_1_9_9">10</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_8" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("2"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_8"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("4"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("4"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_4" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_4" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_10" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you have a problem maintaining an erection strong enough for penetration?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_10">
<li class="gchoice_1_10_0"><input name="input_10" type="radio" value="Always" checked="checked" id="choice_1_10_0"><label for="choice_1_10_0" id="label_1_10_0">Always</label></li>
<li class="gchoice_1_10_1"><input name="input_10" type="radio" value="Sometimes" id="choice_1_10_1"><label for="choice_1_10_1" id="label_1_10_1">Sometimes</label></li>
<li class="gchoice_1_10_2"><input name="input_10" type="radio" value="Never" id="choice_1_10_2"><label for="choice_1_10_2" id="label_1_10_2">Never</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_21" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("3"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("3"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_21"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("5"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("5"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_5" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_5" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_11" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you have diabetes?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_11">
<li class="gchoice_1_11_0"><input name="input_11" type="radio" value="Type 1" id="choice_1_11_0"><label for="choice_1_11_0" id="label_1_11_0">Type 1</label></li>
<li class="gchoice_1_11_1"><input name="input_11" type="radio" value="Type 2" id="choice_1_11_1"><label for="choice_1_11_1" id="label_1_11_1">Type 2</label></li>
<li class="gchoice_1_11_2"><input name="input_11" type="radio" value="No" checked="checked" id="choice_1_11_2"><label for="choice_1_11_2" id="label_1_11_2">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_22" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("4"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("4"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_22"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("6"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("6"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_6" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_6" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_12" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you suffer from anxiety and/or depression?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_12">
<li class="gchoice_1_12_0"><input name="input_12" type="radio" value="Anxiety" id="choice_1_12_0"><label for="choice_1_12_0" id="label_1_12_0">Anxiety</label></li>
<li class="gchoice_1_12_1"><input name="input_12" type="radio" value="Depression" id="choice_1_12_1"><label for="choice_1_12_1" id="label_1_12_1">Depression</label></li>
<li class="gchoice_1_12_2"><input name="input_12" type="radio" value="Both" checked="checked" id="choice_1_12_2"><label for="choice_1_12_2" id="label_1_12_2">Both</label></li>
<li class="gchoice_1_12_3"><input name="input_12" type="radio" value="None" id="choice_1_12_3"><label for="choice_1_12_3" id="label_1_12_3">None</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_23" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("5"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("5"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_23"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("7"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("7"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_7" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_7" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_13" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Have you tested your testosterone levels?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_13">
<li class="gchoice_1_13_0"><input name="input_13" type="radio" value="Yes, normal levels" id="choice_1_13_0"><label for="choice_1_13_0" id="label_1_13_0">Yes, normal levels</label></li>
<li class="gchoice_1_13_1"><input name="input_13" type="radio" value="Yes, low levels" id="choice_1_13_1"><label for="choice_1_13_1" id="label_1_13_1">Yes, low levels</label></li>
<li class="gchoice_1_13_2"><input name="input_13" type="radio" value="No" checked="checked" id="choice_1_13_2"><label for="choice_1_13_2" id="label_1_13_2">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_24" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("6"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("6"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_24"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("8"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("8"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_8" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_8" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_14" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">How do you describe your libido?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_14">
<li class="gchoice_1_14_0"><input name="input_14" type="radio" value="Very Strong" id="choice_1_14_0"><label for="choice_1_14_0" id="label_1_14_0">Very Strong</label></li>
<li class="gchoice_1_14_1"><input name="input_14" type="radio" value="Average" checked="checked" id="choice_1_14_1"><label for="choice_1_14_1" id="label_1_14_1">Average</label></li>
<li class="gchoice_1_14_2"><input name="input_14" type="radio" value="No desire for sex" id="choice_1_14_2"><label for="choice_1_14_2" id="label_1_14_2">No desire for sex</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_26" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("7"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("7"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_26"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("9"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("9"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_9" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_9" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_15" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">How do you describe your partners libido?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_15">
<li class="gchoice_1_15_0"><input name="input_15" type="radio" value="Very Strong" id="choice_1_15_0"><label for="choice_1_15_0" id="label_1_15_0">Very Strong</label></li>
<li class="gchoice_1_15_1"><input name="input_15" type="radio" value="Average" checked="checked" id="choice_1_15_1"><label for="choice_1_15_1" id="label_1_15_1">Average</label></li>
<li class="gchoice_1_15_2"><input name="input_15" type="radio" value="No desire for sex" id="choice_1_15_2"><label for="choice_1_15_2" id="label_1_15_2">No desire for sex</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_27" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("8"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("8"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_27"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("10"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("10"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_10" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_10" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_16" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you suffering from hair loss?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_16">
<li class="gchoice_1_16_0"><input name="input_16" type="radio" value="Yes" checked="checked" id="choice_1_16_0"><label for="choice_1_16_0" id="label_1_16_0">Yes</label></li>
<li class="gchoice_1_16_1"><input name="input_16" type="radio" value="No" id="choice_1_16_1"><label for="choice_1_16_1" id="label_1_16_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_28" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("9"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("9"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_28"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("11"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("11"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_11" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_11" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_29" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you suffering from hair loss?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_29">
<li class="gchoice_1_29_0"><input name="input_29" type="radio" value="Yes" checked="checked" id="choice_1_29_0"><label for="choice_1_29_0" id="label_1_29_0">Yes</label></li>
<li class="gchoice_1_29_1"><input name="input_29" type="radio" value="No" id="choice_1_29_1"><label for="choice_1_29_1" id="label_1_29_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_30" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("10"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("10"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_30"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("12"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("12"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_12" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_12" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_17" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you having trouble sleeping?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_17">
<li class="gchoice_1_17_0"><input name="input_17" type="radio" value="Yes" checked="checked" id="choice_1_17_0"><label for="choice_1_17_0" id="label_1_17_0">Yes</label></li>
<li class="gchoice_1_17_1"><input name="input_17" type="radio" value="No" id="choice_1_17_1"><label for="choice_1_17_1" id="label_1_17_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_31" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("11"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("11"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_31"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("13"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("13"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_13" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_13" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_32" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you smoke?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_32">
<li class="gchoice_1_32_0"><input name="input_32" type="radio" value="Yes" checked="checked" id="choice_1_32_0"><label for="choice_1_32_0" id="label_1_32_0">Yes</label></li>
<li class="gchoice_1_32_1"><input name="input_32" type="radio" value="Yes, but trying to quit" id="choice_1_32_1"><label for="choice_1_32_1" id="label_1_32_1">Yes, but trying to quit</label></li>
<li class="gchoice_1_32_2"><input name="input_32" type="radio" value="No" id="choice_1_32_2"><label for="choice_1_32_2" id="label_1_32_2">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_33" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("12"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("12"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_33"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("14"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("14"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_14" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_14" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_18" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Do you smoke?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_18">
<li class="gchoice_1_18_0"><input name="input_18" type="radio" value="Yes" checked="checked" id="choice_1_18_0"><label for="choice_1_18_0" id="label_1_18_0">Yes</label></li>
<li class="gchoice_1_18_1"><input name="input_18" type="radio" value="Yes, but trying to quit" id="choice_1_18_1"><label for="choice_1_18_1" id="label_1_18_1">Yes, but trying to quit</label></li>
<li class="gchoice_1_18_2"><input name="input_18" type="radio" value="No" id="choice_1_18_2"><label for="choice_1_18_2" id="label_1_18_2">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_34" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("13"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("13"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_34"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("15"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("15"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_15" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_15" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_19" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">Are you experiencing unexplained tiredness?</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_19">
<li class="gchoice_1_19_0"><input name="input_19" type="radio" value="Yes" checked="checked" id="choice_1_19_0"><label for="choice_1_19_0" id="label_1_19_0">Yes</label></li>
<li class="gchoice_1_19_1"><input name="input_19" type="radio" value="No" id="choice_1_19_1"><label for="choice_1_19_1" id="label_1_19_1">No</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_43" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("14"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("14"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_43"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("16"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("16"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_16" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_16" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_42" class="gfield field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label">State of Territory</label>
<div class="ginput_container ginput_container_radio">
<ul class="gfield_radio" id="input_1_42">
<li class="gchoice_1_42_0"><input name="input_42" type="radio" value="NSW" checked="checked" id="choice_1_42_0"><label for="choice_1_42_0" id="label_1_42_0">NSW</label></li>
<li class="gchoice_1_42_1"><input name="input_42" type="radio" value="QLD" id="choice_1_42_1"><label for="choice_1_42_1" id="label_1_42_1">QLD</label></li>
<li class="gchoice_1_42_2"><input name="input_42" type="radio" value="WA" id="choice_1_42_2"><label for="choice_1_42_2" id="label_1_42_2">WA</label></li>
<li class="gchoice_1_42_3"><input name="input_42" type="radio" value="SA" id="choice_1_42_3"><label for="choice_1_42_3" id="label_1_42_3">SA</label></li>
<li class="gchoice_1_42_4"><input name="input_42" type="radio" value="TAS" id="choice_1_42_4"><label for="choice_1_42_4" id="label_1_42_4">TAS</label></li>
<li class="gchoice_1_42_5"><input name="input_42" type="radio" value="NT" id="choice_1_42_5"><label for="choice_1_42_5" id="label_1_42_5">NT</label></li>
<li class="gchoice_1_42_6"><input name="input_42" type="radio" value="ACT" id="choice_1_42_6"><label for="choice_1_42_6" id="label_1_42_6">ACT</label></li>
</ul>
</div>
</li>
</ul>
</div>
<div class="gform_page_footer">
<input type="button" id="gform_previous_button_1_36" class="gform_previous_button button" value="Previous"
onclick="jQuery("#gform_target_page_number_1").val("15"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("15"); jQuery("#gform_1").trigger("submit",[true]); } "> <input type="button" id="gform_next_button_1_36"
class="gform_next_button button" value="Next" onclick="jQuery("#gform_target_page_number_1").val("17"); jQuery("#gform_1").trigger("submit",[true]); "
onkeypress="if( event.keyCode == 13 ){ jQuery("#gform_target_page_number_1").val("17"); jQuery("#gform_1").trigger("submit",[true]); } ">
</div>
</div>
<div id="gform_page_1_17" class="gform_page" style="display:none;">
<div class="gform_page_fields">
<ul id="gform_fields_1_17" class="gform_fields top_label form_sublabel_below description_below">
<li id="field_1_41" class="gfield formtitle gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible">
<h3>Based on your answers you may have a sexual health issue. Please enter your details for your customised assessment to be sent discreetly to you via SMS or email.</h3>
</li>
<li id="field_1_37" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_1_37">First Name<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_37" id="input_1_37" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_1_38" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_1_38">Last Name<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_text"><input name="input_38" id="input_1_38" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
<li id="field_1_39" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_1_39">Email<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_email">
<input name="input_39" id="input_1_39" type="text" value="" class="medium" aria-required="true" aria-invalid="false">
</div>
</li>
<li id="field_1_40" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible"><label class="gfield_label" for="input_1_40">Mobile Number<span class="gfield_required">*</span></label>
<div class="ginput_container ginput_container_phone"><input name="input_40" id="input_1_40" type="text" value="" class="medium" aria-required="true" aria-invalid="false"></div>
</li>
</ul>
</div>
<div class="gform_page_footer top_label"><input type="submit" id="gform_previous_button_1" class="gform_previous_button button" value="Previous"
onclick="if(window["gf_submitting_1"]){return false;} window["gf_submitting_1"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} window["gf_submitting_1"]=true; jQuery("#gform_1").trigger("submit",[true]); }"> <input type="submit"
id="gform_submit_button_1" class="gform_button button" value="Submit" onclick="if(window["gf_submitting_1"]){return false;} window["gf_submitting_1"]=true; "
onkeypress="if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} window["gf_submitting_1"]=true; jQuery("#gform_1").trigger("submit",[true]); }"> <input type="hidden"
name="gform_ajax" value="form_id=1&title=&description=&tabindex=0">
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* About us
* Terms and Conditions
* Privacy Policy
1300 564 048 info@climaxclinic.com.au
* Erectile Dysfunction
* Premature Ejaculation
* Low T
* Treatment Cost
* Faq’s
* About
* Leaders in sexual health.
Accredited Australian Doctors
Re-igniting confidence in men
Australia wide service
PE
ED
LOW T
Please select which self assessment quiz you would like to start
* Leaders in sexual health.
Accredited Australian Doctors
Re-igniting confidence in men
Australia wide service
Begin Assesment
* Proudly Supporting
DO AN ASSESSMENT
Fill out this quiz to determine if you have an issue.
SPEAK TO YOUR DOCTOR
Our highly experienced Doctors are available for a private video or phone
consult at your convenience.
CHOOSE THE RIGHT TREATMENT
Upon the Doctors advice, you will be offered customised and affordable treatment
plans.
BEGIN TREATMENT
Licenced Australian Doctors are with you every step of the way.
WELCOME TO THE CLIMAX CLINIC
The Climax Clinic is a leader in the tailored treatment of Erectile
Dysfunction(ED), Premature Ejaculation (PE) and Testosterone Deficiency (TD). A
third of men suffer from sexual dysfunction. Many are suffering in silence.
Having a problem is nothing to be ashamed of. Not doing something about it is. A
tailored and effective plan is available at an affordable price.
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FREQUENTLY ASKED QUESTIONS (FAQ’S)
WILL I GET REHABILITATED?
Your Climax Clinic doctor will be able to answer this question for you, since
this depends on each individual and also which condition you suffer from.
Although results are immediate in most cases, typically you will be fully
rehabilitated within 12 months.
WHY THE CLIMAX CLINIC?
Because our goal is to take a leadership position in the Male Sexual Health
arena. We embrace technology which means we are able to reach more people,
provide greater convenience and give a superior service that focuses on the
patient by working within their specific needs.
WHAT IS TESTOSTERONE DEFICIENCY?
Testosterone Deficiency, Andropause, Male Menopause , and Irritable/Grumpy Old
Man Syndrome are all names given for declining testosterone levels in men. The
same way declining oestrogen levels lead to menopause in women, a similar
decline in the male hormone, testosterone, can cause a variety of symptoms in
men, typically a decline in sex-drive, energy and mood.
CAN I HAVE A CONSULTATION OVER THE PHONE?
Yes you can. We have Australian Registered Doctors and Clinical Support
Consultants that are fully trained to conduct telephone consultations.
WILL THE TREATMENT ‘CLASH’ WITH MY CURRENT MEDICATION?
Only a Doctor can answer this question. The best way to find out is to speak to
one of our Doctors.
TREATMENT COST
WHAT OUR PATIENTS SAY
RJ T
July 21, 2023
two thumbs up and a big smile
I have had a flawless experience with them and their new doctor is very good. I
have also delt with sarah who is always understanding and nothing is a hassle,
even tho i can imagine she is always busy but is always professional. Their
treatment has moved to a compound formula to keep up with modern medicine.
Highly recommend the company as being a nurse its awesome to be able to advocate
for your own health holistically.
From RJ
Rabih Kassir
May 31, 2023
Saved my life, thank you climax clinic
maher maher
May 11, 2023
شكرا لكل الكادر الطبي وتنصح بالقدوم لهذا المركز الافضل في اسطنبول
Rocco Zagari
October 17, 2022
Appreciate the help and assistance from staff, in particular from Virgil.
Adam Rowlands
October 17, 2022
Vergel & the team where always on hand to answer any questions & ensured that I
received the maximum benifit of my treatment. I highly recommend!
Craig deans
October 6, 2022
I can't thank the climax clinic enough
With so many scams happing lately people are hard to trust in this world.
Thats not the case with the climax clinic I can't thank there help enough.
They tailored a solution to my personal needs there products are extremely
effective I couldn't be happy with there service.
Highly recommended
Gareth Michael
September 30, 2022
Fantastic customer service. Prompt and on time delivery, I have nothing but
great things to say about Vergel and Climax Clinic.
I recommend them highly.
Jack Ramsay
September 30, 2022
Great product
Daniel
September 21, 2022
Very very thankful for all the help I have received! I was feeling terrible for
a long time and made the decision to work with Vergil and couldn’t be happier.
My energy is back to where it should be and being a father of 2 young boys I
really needed some help. I have no regrets at all! Money well spent. Thank you
for everything.
Billy Polson
July 25, 2022
These guys are the real deal. Reall helpful and have access to a huge range of
products! I found them really easy to speak to and they came up with a solutoin
that was not too expensive and solved my problem. I highly recommend them!
Andrew Baldin
July 17, 2022
I looked into this about 3 months ago and definitely recommend this to any
friends/men. It's helped me immensely. Thank you to all at the Climax Clinic for
their help.
Pat McFarland
April 7, 2022
Vergel and his team are the best in the market!
JT
February 20, 2022
Can’t recommend the Climax Clinic enough.
Their products have lifted my confidence completely.
Customer service is of a high level - special thanks to Vergel for his ongoing
support.
George Agapides
February 3, 2022
Before climax clinic I lacked energy, I was waking up tired, micro sleeping on
the way to work, certain foods affected me bloating, water retention etc. Since
being with climax I’ve never felt better. 10/10!
Rex Harris
January 27, 2022
Mirza Kovacevic
November 8, 2021
Great product, working wonders so far! Had issues with low Testosterone and
Vergil was quick to assist. Highly recommended! A+++
Clayton Nicholls
November 4, 2021
I found the company to have great customer service . And the product to work
very well I’ve noticed a boost in energy levels and more drive in strenuous
activity
Robert Edwards
October 10, 2021
Very well looked after by the medical and support team
Adam Adams
September 29, 2021
Wonderful staff and amazing communication skills. Verg goes above and beyond for
customer satisfaction ; fast delivery and they always answer my questions with
proper knowledgeable answers. I appreciate their services and definitely
recommend them . Wish I could give more than 5 stars
Danny Dang
September 24, 2021
Great Service and very informative from staff and specialists.
Mark D Brown
September 22, 2021
Stoic Wolf
September 19, 2021
These guys are absolutely amazing. Incredibly friendly, and take the time to
explain through and through what their products do, what they aim to achieve and
how they will effect you personally.
Highly recommend. I specifically used it for TRT, and I’m a month in, feeling
better than ever.
Cheers,
Special thanks to Vergel.
Netava Labalaba
September 17, 2021
The tablets was amazing. I've tried other offers from agencies and this one is
the best..Strong in erection and increased in size.
I'm now satisfied 100^ after the previous frustration I went through during love
making.
Daniel Shaw
September 14, 2021
Petar troselj Troselj
September 9, 2021
John Tsagarakis
September 1, 2021
Adam Murray
September 1, 2021
Great Clinic, easy to deal with and really looked after me. Highly Recommend
Jay Jay
September 1, 2021
Amazing service and care. Staff are always super helpful about any questions I
had and the whole process was a breeze. Highly recommend the Climax Clinic.
Ben Chilby
September 1, 2021
Great customer service, very professional and dependable! Highly reccomend!
Johnathan Reynolds
August 24, 2021
"I feel 20 years younger, I’ve got my edge back, not only in my personal life
but in business too. I’m more assertive without being aggressive, and stuff just
seems to get done when it never used to before. Being recently divorced this is
the kick-start I needed. It’s great to be young and vibrant again. Highly
recommend the Climax Clinic they have changed my life
READY TO START?
There’s no need to suffer in silence! Take the Self Assessment quiz
Begin Assesment
CONTACT INFO
Level 7 / 233, Castlereagh St, Sydney
Phone : 1300 564 048 | (02) 7227 7384
Email : info@climaxclinic.com.au
Web : climaxclinic.com.au
*
*
*
*
*
PROUDLY SUPPORTING
SITEMAP
* Erectile Dysfunction
* Premature Ejaculation
* Low T
* Treatment Cost
* Faq’s
* About
LOCATION
PROUDLY SUPPORTING
Copyright © 2020 Climax Clinic. All Rights Reserved. Design Themes
* Do you have a problem maintaining an erection strong enough for penetration?
* Always
* Sometimes
* Never
* On a scale of 1 - 10 (with 10 being strong) how strong is your average
erection?
* 1
* 2
* 3
* 4
* 5
* 6
* 7
* 8
* 9
* 10
* How many minutes are you currently lasting before ejaculating?
* 1
* 2
* 3
* 4
* 5
* 6
* 7
* 8
* 9
* 10
* Do you have a problem maintaining an erection strong enough for penetration?
* Always
* Sometimes
* Never
* Do you have diabetes?
* Type 1
* Type 2
* No
* Do you suffer from anxiety and/or depression?
* Anxiety
* Depression
* Both
* None
* Have you tested your testosterone levels?
* Yes, normal levels
* Yes, low levels
* No
* How do you describe your libido?
* Very Strong
* Average
* No desire for sex
* How do you describe your partners libido?
* Very Strong
* Average
* No desire for sex
* Are you suffering from hair loss?
* Yes
* No
* Are you having trouble sleeping?
* Yes
* No
* Do you smoke?
* Yes
* Yes, but trying to quit
* No
* Are you experiencing unexplained tiredness?
* Yes
* No
* State of Territory
* NSW
* QLD
* WA
* SA
* TAS
* NT
* ACT
* BASED ON YOUR ANSWERS YOU MAY HAVE A SEXUAL HEALTH ISSUE. PLEASE ENTER YOUR
DETAILS FOR YOUR CUSTOMISED ASSESSMENT TO BE SENT DISCREETLY TO YOU VIA SMS
OR EMAIL.
* First Name*
* Last Name*
* Email*
* Mobile Number*
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×
* REQUEST YOUR FREE CONSULTATION
Fill in the form below and one of our consultants will contact you to book
your consultation.
* Name*
* Age*
* Phone*
* Email*
* Nature of Enquiry*
Nature of EnquiryErectile DysfunctionPremature EjaculationLow Testosterone
* Where did you hear about us*
Where did you hear about usGoogleFacebookFriendRadioReferred by
FriendReferred by Medical PractitionerTVOther
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We abide by our privacy statement. Your information will not be shared
×
STEP 1 OF 11
9%
* Is your erection strength decreasing?
* Yes
* No
* Do you feel tired all the time?
* Yes
* No
* How often do you want to have sex?
* Daily
* Monthly
* Never
* Are you experiencing mood swings?
* Always
* Sometimes
* No, mood is stable
* Do you lack motivation and drive?
* Always
* Sometimes
* Never
* Do you have trouble sleeping?
* Always
* Sometimes
* Never
* Are you experiencing anxiety and/or depression?
* Yes
* Sometimes
* Never
* Are you putting on weight?
* Yes
* No
* Are you experiencing hair loss?
* Yes
* No
* State of Territory
* NSW
* QLD
* WA
* SA
* TAS
* NT
* ACT
* Based on your answers you may have a sexual health issue. Please enter your
details for your customised assessment to be sent discreetly to you via SMS
or email.
* First Name*
* Last Name*
* Email*
* Mobile Number*
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×
STEP 1 OF 9
11%
* Are you able to control your ejacluation?
* Always
* Sometimes
* Never
* Are you able to satisfy your partner?
* Always
* Sometimes
* Never
* How long are you currently lasting during intercourse?
* <1 minute
* < 2- 4 minute
* 5+ minutes
* Are you satisfied with the length it takes you to ejaculate?
* Yes
* No
* Are you satisfied with the length it takes you to ejacuate?
* Yes
* No
* Do you avoid sex for fear of embarrassment and disappointment?
* Always
* Sometimes
* Never
* Is it getting worst with time?
* Yes
* No
* State of Territory
* NSW
* QLD
* WA
* SA
* TAS
* NT
* ACT
* Based on your answers you may have a sexual health issue. Please enter your
details for your customised assessment to be sent discreetly to you via SMS
or email.
* First Name*
* Last Name*
* Email*
* Mobile Number*
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×
STEP 1 OF 9
11%
* How often can you get an erection?
* Always
* Sometimes
* Rarely
* Never
* Is your erection firm enough to have sex?
* Always
* Sometimes
* Rarely
* Never
* Once an erection is gained, can you keep it during sex?
* Always
* Sometimes
* Rarely
* Never
* If you lose the erection, can you get it back?
* Always
* Sometimes
* Rarely
* Never
* Are you satisfied with the length it takes you to ejacuate?
* Yes
* No
* Are you able to control your ejacuation?
* Always
* Sometimes
* Never
* Are you able to satisfy your partner?
* Always
* Sometimes
* Never
* State of Territory
* NSW
* QLD
* WA
* SA
* TAS
* NT
* ACT
* Based on your answers you may have a sexual health issue. Please enter your
details for your customised assessment to be sent discreetly to you via SMS
or email.
* First Name*
* Last Name*
* Email*
* Mobile Number*
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×
* Do you have a problem maintaining an erection strong enough for penetration?
* Always
* Sometimes
* Never
* On a scale of 1 - 10 (with 10 being strong) how strong is your average
erection?
* 1
* 2
* 3
* 4
* 5
* 6
* 7
* 8
* 9
* 10
* How many minutes are you currently lasting before ejaculating?
* 1
* 2
* 3
* 4
* 5
* 6
* 7
* 8
* 9
* 10
* Do you have a problem maintaining an erection strong enough for penetration?
* Always
* Sometimes
* Never
* Do you have diabetes?
* Type 1
* Type 2
* No
* Do you suffer from anxiety and/or depression?
* Anxiety
* Depression
* Both
* None
* Have you tested your testosterone levels?
* Yes, normal levels
* Yes, low levels
* No
* How do you describe your libido?
* Very Strong
* Average
* No desire for sex
* How do you describe your partners libido?
* Very Strong
* Average
* No desire for sex
* Are you suffering from hair loss?
* Yes
* No
* Are you suffering from hair loss?
* Yes
* No
* Are you having trouble sleeping?
* Yes
* No
* Do you smoke?
* Yes
* Yes, but trying to quit
* No
* Do you smoke?
* Yes
* Yes, but trying to quit
* No
* Are you experiencing unexplained tiredness?
* Yes
* No
* State of Territory
* NSW
* QLD
* WA
* SA
* TAS
* NT
* ACT
* BASED ON YOUR ANSWERS YOU MAY HAVE A SEXUAL HEALTH ISSUE. PLEASE ENTER YOUR
DETAILS FOR YOUR CUSTOMISED ASSESSMENT TO BE SENT DISCREETLY TO YOU VIA SMS
OR EMAIL.
* First Name*
* Last Name*
* Email*
* Mobile Number*
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×
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