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For Physicians
Erectile Function Questionnaire
Home
Erectile Function Questionnaire
Erectile Dysfunction
Step
1
of
68
1%
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
(Required)
(By entering your phone number, you consent to be contacted through call and/or text on the phone number you enter.)
Email
(Required)
(By entering your email address, you consent to be contacted via email at the email address you provide.)
I opt to receive promotional information and clinic announcements on this number
I opt to receive promotional information and clinic announcements on this email
Which of the following conditions apply to you at the moment:
I suffer from anxiety or stress.
Yes
No
Sometimes
My sexual relationships are lacking or problematic.
Yes
No
Sometimes
I lack confidence with my ability to perform sexually.
Yes
No
Sometimes
I have difficulty in arousal.
Yes
No
Sometimes
I have difficulty reaching orgasm.
Yes
No
Sometimes
I have problems with premature ejaculation.
Yes
No
Sometimes
I have pain during intercourse.
Yes
No
Sometimes
I have a concern about the size of my penis.
Yes
No
Sometimes
I lack energy.
Yes
No
Sometimes
I have a low libido or sex drive.
Yes
No
Sometimes
I sleep poorly.
Yes
No
Sometimes
I have concerns about how I/my body parts look.
Yes
No
Sometimes
GENERAL HEALTH HISTORY
Please indicate if you have any of the following health conditions:
Heart disease
Yes
No
Diabetes
Yes
No
High Blood Pressure
Yes
No
High Cholesterol or Triglyceride
Yes
No
Parkinson’s disease
Yes
No
Multiple Sclerosis (MS)
Yes
No
Have you had any back, neck, or spinal cord injuries?
Yes
No
Do you have difficulty urinating?
Yes
No
Do you often get cold or numbness in your hands or feet?
Yes
No
Have you had a tumor or undergone surgery or radiation in the pelvic or genital region?
Yes
No
International Index of Erectile Function (IIEF-5)
(without pills)
Answer the following questions considering your sexual function without taking any pills like Viagra or Cialis (if applicable):
1. OVER THE PAST 6 MONTHS, how do you rate your confidence that you could get and keep an erection? (Without pills)
Very low
Low
Moderate
High
Very high
2. OVER THE PAST 6 MONTHS, when you had erections with sexual stimulation, how often were your erections hard enough for penetration? (Without pills)
Almost never/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. OVER THE PAST 6 MONTHS, during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? (Without pills)
Almost never/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. OVER THE PAST 6 MONTHS, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? (Without pills)
Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult
5. OVER THE PAST 6 MONTHS, when you attempted sexual intercourse, how often was it satisfactory for you? (Without pills)
Almost never/never
A few times (much less than half the time)
Sometimes (about half the time)
Most times
Almost always or always
International Index of Erectile Function (IIEF-5)
(with pills)
Answer the following questions considering your sexual function with the help of pills like Viagra or Cialis (if applicable):
1. OVER THE PAST 6 MONTHS, how do you rate your confidence that you could get and keep an erection? (With pills - if applicable)
Very low
Low
Moderate
High
Very high
2. OVER THE PAST 6 MONTHS, when you had erections with sexual stimulation, how often were your erections hard enough for penetration? (With pills - if applicable)
Almost never/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. OVER THE PAST 6 MONTHS, during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? (With pills - if applicable)
Almost never/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. OVER THE PAST 6 MONTHS, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? (With pills - if applicable)
Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult
5. OVER THE PAST 6 MONTHS, when you attempted sexual intercourse, how often was it satisfactory for you? (With pills - if applicable)
Almost never/never
A few times (much less than half the time)
Sometimes (about half the time)
Most times
Almost always or always
Penis hardness score:
How would you describe your penis situation when you get your best erection (without pills)?
0 Penis is flaccid
1 Penis is larger than normal, but not hard
2 Penis is hard, but not hard enough for penetration
3 Penis is hard enough for penetration but not completely hard,
4 Penis is completely hard and fully rigid
How would you describe your penis situation when you get your best erection (with pills – if applicable)?
0 Penis is flaccid
1 Penis is larger than normal, but not hard
2 Penis is hard, but not hard enough for penetration
3 Penis is hard enough for penetration but not completely hard,
4 Penis is completely hard and fully rigid
ADAM Questionnaire:
1. Do you have a decrease in libido (sex drive)?
Yes
No
2. Do you have a lack of energy?
Yes
No
3. Do you have a decrease in strength and/or endurance?
Yes
No
4. Have you lost height?
Yes
No
5. Have you noticed a decreased "enjoyment of life"?
Yes
No
6. Are you sad and/or grumpy?
Yes
No
7. Are your erections less strong?
Yes
No
8. Have you noticed a recent deterioration in your ability to play sports?
Yes
No
9. Are you falling asleep after dinner?
Yes
No
10. Has there been a recent deterioration in your work performance?
Yes
No
Life style questionnaire:
What is your height? …….. Feet/Inch/cm
What is your weight? …….. lbs./Kg
Feet/Inch
cm
kg
Ibs
What sort of exercise have you had in the past week? (select as many as apply)
What sort of exercise have you had in the past week? (select as many as apply)
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?
0
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
No
How many years of smoking tobacco products do you have?
0
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?
0
1-4
5-10
11-20
21-30
30-40
more than 40
Have you ever used marijuana products?
No
In the past
Using now
How many years in total have you used marijuana products?
0
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? (Select all that apply)
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 past month, when you had sexual stimulation or intercourse, how often did you ejaculate?
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
No Orgasm
Are you currently in a relationship and have a regular sex partner?
Yes
No
List of medications:
List the prescription medications you are taking currently or recently.
Add
Remove
List the naturopathic and herbal medicines you take regularly.
Add
Remove
List other over-the-counter, non-prescription medications you take regularly.
Add
Remove
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
No
Medications for stress or depression.
Yes
No
Medications for other mental health conditions.
Yes
No
Which of the following do you feel you might benefit from
Which of the following do you feel you might benefit from ? (select all that apply)
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
