Erectile Dysfunction Questionaire
PRESENT SEXUAL FUNCTION
1
Over the past 30 days, how often have you had partial or full erections when you were sexually stimulated in any way?
Did not engage in any sexual activity
Almost never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always/always
2
Over the past 30 days, when you had erections, how often were the erections firm enough to have sexual relations?
Did not engage in any sexual activity
Almost never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always/always
3
When you attempted sexual intercourse, how often were you able to penetrate (enter) your partner?
Did not attempt intercourse
Almost never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always/always
4
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
Unable to attempt intercourse
Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult
5
When you attempted sexual intercourse, how often was your erection satisfactory in your opinion?
Did not engage in any sexual activity
Almost never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (much more than half the time)
Almost always/always
6
How would you rate your level of sexual desire?
Very low/none at all
Low
Moderate
High
Very high
7
What is the quality of the best erection you have experienced during the night or upon awakening in the morning during the past month?
None at all
Partial (less than half)
Partial (better than half)
Full erection
What is the rigidity of your penis upon achieving orgasm?
Unable to achieve orgasm
No erection at all
Partial (equal to or less than half erect)
Partial (better than half erect)
Full erection
8
Do you have an active sexual partner at this time?
Yes
No
9
Can you achieve an orgasm?
Yes
No
10
Can you ejaculate normally?
Yes
No
11
Do you have premature ejaculation?
Yes
No
12
Do you think there is an emotional cause?
Yes
No
13
Do you experience any pain with erections?
Yes
No
14
Are or were your erections abnormally bent?
Yes
No
If so, which direction is it bent?
Up
Down
Left
Right
How many degrees is the bend?
15
Have you noted any change in the bend during the past six months?
Yes
No
PAST MEDICAL HISTORY
16
Are you being treated for diabetes mellitus?
Yes
No
If yes so, which treatment method are you using to control your sugar?
Diet
Pills
Insulin
17
Are you being treated for high blood pressure?
Yes
No
18
Are you being treated for elevated blood cholesterol level?
Yes
No
19
Do you have heart disease?
Yes
No
20
Have you ever had a stroke?
Yes
No
21
Have you been told that you have hardening of the arteries?
Yes
No
22
Are you or have you been treated for depression?
Yes
No
Clear
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