Erectile Dysfunction Step 1 of 55 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 NumberEmail(Required) 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 HISTORYPlease indicate if you have any of the following health conditions: Heart disease Yes No Diabetes 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 See what your erectile function score isClick Here Penis hardness score:0. Penis is flaccid1. Penis is larger than normal, but not hard2. Penis is hard, but not hard enough for penetration3. Penis is hard enough for penetration but not completely hard,4. Penis is completely hard and fully rigid Testosterone Deficiency Questionnaire ADAM (Androgen Deficiency in Aging Male) 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 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? 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? 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 No List of medications:List the prescription medications you are taking currently or recently. Add RemoveList the naturopathic and herbal medicines you take regularly. Add RemoveList other over-the-counter, non-prescription medications you take regularly. Add Remove MENTAL HEALTHAre 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 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