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"*" indicates required fields

Gender*

Age Range*

Is your current sex life satisfying?

What are you experiencing?*

Male

Low Libido

Decreased Sensitivity

Decrease in Performance

Inability to have an Orgasm

Painful Intercourse

Decreased Sex Drive

Premature Ejaculation

Abnormal Penile Curvature/Peyronie's Disease

Erectile Disfunction

BXO Penis

Urinary Incontinence

Interstitial Cystitis

Decreased Nipple Sensitivity

Abnormal Skin Changes

Dry Wrinkled Skin

Weight Gain

Hair Loss/Breakage

General Body Image

Fatigue

Mood Changes

Decreased Mental Ability/Focus

Hot Flashes/Night Sweats

Sleep Problems

Always Cold

What are you experiencing?*

Other

Low Libido

Decreased Sensitivity

Decrease in Performance

Decreased Sex Drive

Painful Intercourse

Inability to have an Orgasm

Decreased Nipple Sensitivity

Vaginal Dryness

Sagging Breasts

Erectile Disfunction

Abnormal Penile Curvature/Peyronie's Disease

Premature Ejaculation

Interstitial Cystitis

Urinary Incontinence

Abnormal Skin Changes

Weight Gain

General Body Image

Dry Wrinkled Skin

Hair Loss/Breakage

Fatigue

Mood Changes

Decreased Mental Ability/Focus

Hot Flashes/Night Sweats

Sleep Problems

Always Cold

What are you experiencing?*

Female

Low Libido

Vaginal Dryness

Decreased Sex Drive

Decreased Sensitivity

Inability to have an Orgasm

Lichen Sclerosus

Painful Intercourse

Urinary Incontinence

Interstitial Cystitis

Decreased Nipple Sensitivity

Sagging Breasts

Abnormal Skin Changes

Weight Gain

General Body Image

Dry Wrinkled Skin

Hair Loss/Breakage

Fatigue

Mood Changes

Decreased Mental Ability/Focus

Hot Flashes/Night Sweats

Sleep Problems

Always Cold

How long have you been experiencing these issues?*

What is your current relationship status?*

Have you tried, or are you trying, any other treatments?*

What treatments have you tried, or are you trying?

ex: Viagra or Cialis

Do you have, or have you had any of the following?*

Diabetes

Heart Disease

High Blood Pressure

Depression/Anxiety

Prostate Cancer/Surgery

Breast Cancer

Penile Implant

Dialysis

None

Is there anything else that you would like us to know?

Name

First Last

Email*

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Phone*

Comments

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Disclaimer:

*Every patient is different and may experience different results from participating in any of our programs. Please discuss goals and expectations with our medical providers. Please note that your appointment will not be fully booked until a member of our staff calls to finalize the appointment.
A $50 booking fee must be paid over the phone to secure your appointment. All fees go towards your first visit.

Also Serving: D’Iberville, MS, Bay Saint Louis, MS, Diamondhead, MS, Biloxi, MS, Long Beach, MS, Pass Christian, MS, Ocean Springs, MS, Gautier, MS, Pascagoula, MS, Saucier, MS, Wiggins, MS, Waveland, MS

Gulf Coast Networking

Interest-free financing

CareCredit Interest-Free financing options allow qualifying patients to receive treatments starting at as little as $84/month!

Care Credit Apply Now

Phone: (228) 206-0542
Email: manager@healthfitmd.com

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15429 O’Neal Road, Gulfport, MS 39503
Fax: (228) 206-0550

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