Erectile Function Questionnaire

Erectile Dysfunction

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Please answer these questions about your current medical status so that we can determine if a consultation with one of our physicians is necessary. Knowing this information will make the medical consultation maximally productive.

Your answers to the questions will be kept confidential. If you are unsure how to answer or feel uncomfortable answering any of the questions you can skip over them.

Name(Required)

First Name Family Name

Phone Number

Email(Required)

Which of the following conditions apply to you at the moment:

I suffer from anxiety or stress.

Yes

Sometimes

My sexual relationships are lacking or problematic.

Yes

Sometimes

I lack confidence with my ability to perform sexually.

Yes

Sometimes

I have difficulty in arousal.

Yes

Sometimes

I have difficulty reaching orgasm.

Yes

Sometimes

I have problems with premature ejaculation.

Yes

Sometimes

I have pain during intercourse.

Yes

Sometimes

I have a concern about the size of my penis.

Yes

Sometimes

I lack energy.

Yes

Sometimes

I have a low libido or sex drive.

Yes

Sometimes

I sleep poorly.

Yes

Sometimes

I have concerns about how I/my body parts look.

Yes

Sometimes

GENERAL HEALTH HISTORY

Please indicate if you have any of the following health conditions:

Heart disease

Yes

Diabetes

Yes

Parkinson’s disease

Yes

Multiple Sclerosis (MS)

Yes

Have you had any back, neck, or spinal cord injuries?

Yes

Do you have difficulty urinating?

Yes

Do you often get cold or numbness in your hands or feet?

Yes

Have you had a tumor or undergone surgery or radiation in the pelvic or genital region?

Yes

See what your erectile function score is

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Penis hardness score:

Testosterone Deficiency Questionnaire

ADAM (Androgen Deficiency in Aging Male) Questionnaire:

1. Do you have a decrease in libido (sex drive)?

Yes

2. Do you have a lack of energy?

Yes

3. Do you have a decrease in strength and/or endurance?

Yes

4. Have you lost height?

Yes

5. Have you noticed a decreased "enjoyment of life"?

Yes

6. Are you sad and/or grumpy?

Yes

7. Are your erections less strong?

Yes

8. Have you noticed a recent deterioration in your ability to play sports?

Yes

9. Are you falling asleep after dinner?

Yes

10. Has there been a recent deterioration in your work performance?

Yes

Life style questionnaire:

What is your height? …….. Feet/Inch/cm

What is your weight? …….. lbs./Kg

What sort of exercise have you had in the past week?

Walking

Cycling

Swimming

Running

Team Sports

Weights

Other

No Physical Activity

In total, how many hours of exercise have you had in the past week?

1-2

3-4

5-6

7 or more

How many caffeinated beverages do you have per day, on average? (e.g., coffee, tea, or pop)

0-1

2-3

4-6

more than 6

How often do you have a drink containing alcohol?

Never In the past

Monthly or less

2-4 times per month

2-3 times per week

4-6 times per week

Everyday

Do you smoke tobacco containing products?

Yes

How many years of smoking tobacco products do you have?

Less than 1

1-5

6-10

11-20

More than 20

How many cigarettes have you smoked per day during your smoking years in average?

1-4

5-10

11-20

21-30

30-40

more than 40

Have you ever used marijuana products?

In the past

Using now

How many years in total have you used marijuana products?

Less than 1

1-5

6-10

11-20

More than 20

How long have you had difficulties with erections?

Less than one month

1-6 months

7-12 months

1-3 years

More than 3 years

How quickly did the problem start?

Gradually over years

Gradually over months

Over a few weeks

Suddenly

Over the last month when were you able to achieve an erection?

During foreplay

Immediately prior to intercourse

During intercourse

During other sexual activity

First thing in the morning

When alone

Over the last month, how many times have you attempted sexual intercourse?

No attempts

1-2 attempts

3-4 attempts

5-6 attempts

7-10 attempts

11 or more attempts

Over the last month, when you attempted sexual intercourse how often was it satisfactory for you?

No attempts

Almost never or never

A few times (much less than half the times)

Sometimes (about half the times)

Most times (much more than half the times)

Almost always or always

Over the last month, when you had sexual stimulation or intercourse, how often did you have an orgasm?

No attempts

Almost never or never

A few times (much less than half the times)

Sometimes (about half the times)

Most times (much more than half the times)

Almost always or always

Over the last month, when you had sexual stimulation or intercourse, how often did you have an orgasm?

No attempts

Almost never or never

A few times (much less than half the times)

Sometimes (about half the times)

Most times (much more than half the times)

Almost always or always

Did your orgasms occur with or without ejaculation?

With

Without

Are you currently in a relationship and have a regular sex partner?

Yes

List of medications:

List the prescription medications you are taking currently or recently.

List the naturopathic and herbal medicines you take regularly.

List other over-the-counter, non-prescription medications you take regularly.

MENTAL HEALTH

Are you undergoing treatment for mental health challenges? Please select yes or no for each option below.

Seeing a counselor or therapist.

Yes

Medications for stress or depression.

Yes

Medications for other mental health conditions.

Yes

Which of the following do you feel you might benefit from

Reduce conflict and stress in your personal relationships

Improve ability to have satisfying sex

Greater feeling of intimacy and love

Increase creativity and playfulness in your sexual relationships

Greater sexual confidence

Improve ability to provide sexual satisfaction for your partner

More freedom to communicate your sexual desires

Improve self-image

Increase understanding and support from your partner

Erectile Dysfunction

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