PLEASE CIRCLE THE MOST ACCURATE ANSWER OR FILL IN THE BLANKS |
| 1. Do you have problems (obtaining), (maintaining) an erection or (both)? |
2. When did you first notice a change in your sexual function?
(Approximate year/month):________________________________ |
| 3. Do you recall any significant events which occurred around the same time? ( ) No ( ) Yes (Please circle any event that occurred): (Marital/sexual partner problems) (Loss of job) (Financial problems) (Death in family) (Illness or injury) |
THE FOLLOWING QUESTIONS ASK YOU TO GRADE THE QUALITY OF YOUR ERECTIONS - PLEASE CIRCLE THE NUMBER THAT BEST DESCRIBES THE QUALITY OF YOUR ERECTIONS |
| As a guide, anything less than a 7 cannot be pushed into the vagina. A 10 is a fully "rock-hard" erection. Please answer this question regarding your penile rigidity while imagining that your penis has no curvature. |
| No Erections (0) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) Full Erections |
4. Do you have an (erection) or (semi-erection) in the morning before you urinate? ( ) No ( ) Yes (How often?):____________________________________________
GRADE: (0) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) |
5. Do you ever awaken at night and notice an (erection) or (semi-erection)? ( ) No ( ) Yes (How often?):___________________________________________
GRADE: (0) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) |
6. Do other types of stimulus improve your erections such as: (masturbation) (oral sex) (erotic films) (reading material)? ( ) No ( ) Yes
GRADE: (0) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) |
7. Are your erections ever firm enough for vaginal penetration ( ) No ( ) Yes
(How often?)_________________________________________________________________ |
| 8. Do you ever notice any (increase) (decrease) in your erections with position changes? ( ) No ( ) Yes (Please explain):__________________________________________ |
| 9. Are you concerned about the appearance of your epnis such as: (bend or curvature) (color change) (lumps) (loss of length)? ( ) No ( ) Yes: (Please explain):____________________________________________________________________ |
| 10. When was the last time you had successful intercourse?________________________ |
| 11. Do you consider your desire for sex normal? ( ) Yes ( ) No (decreased) (no desire) |
|
12. Are you able to ejaculate? ( ) No ( ) Yes (By what method?) (intercourse)
(masturbation) (oral sex) Does the semen: (spurt out) (flow out slowly) (goes backward into the bladder) |
| 13. Do you have premature ejaculation? ( ) No ( ) Yes (Has it been): (lifelong) (recent onset) |
14. Have you noticed any change in the sensation of your penis? ( ) No ( ) Yes:
(decreased) (increased) (numbness) Date first noticed change in sensation___________ |
| 15. Has your problem with sexual dysfunction affected your relationship with your partner? ( ) No ( ) Yes or do not have a sexual partner relationship at this time ( ) |
16. In the past, have you received treatment for (erectile dysfunction) and/or (premature ejaculation)? ( ) No ( ) Yes: (oral medication:____________________) (vacuum device)
(penile injections) (testosterone patches or injections) (surgery/implants).
Please list approximate dates of previous treatment:________________________________ |
Are you currently using medications prescribed for erectile dysfunction or a vacuum device?
( ) No ( ) Yes: If yes, please explain:___________________________________________ |
17. Do you have any problems with urination? ( ) No ( ) Yes: (Please indicate your problem)
- Frequency during the: (daytime) (at night)
- (Urgency) and/or (leakage) of urine: (rarely) (sometimes) (almost always)
Difficulty starting stream: rarely) (sometimes) (almost always) |
18. Are you taking medications including those you may not take on a regular basis? ( ) No ( ) Yes (Please list all medications):____________________________________
___________________________________________________________________________ |
| Do you have (diabetes), (high blood pressure), (poor circulation), (heart problems), (cancer), (ulcers), (bleeding problems), (retinitis pigmentosa), (renal failure) |
| 19. In the past, have you had major surgery to your: (back/spine) (prostate) (heart/blood vessels) (penis) (organ transplant_______________) (bowel) (urinary bladder/urethra). Please indicate date(s) of surgery:_______________________________________________ |
| 20. Do you have problems with (climbing 1 or 2 flights of stairs) or (walking 5 or 6 blocks)? ( ) No ( ) Yes: (shortness of breath) (leg pains) (weakness) (angina/chest pain) |
21. Tobacco use: (never smoked) (currently smoke) (smoked in the past). (Circle the tobacco product you use or have used): (cigarettes) (cigars) (pipes). How long:___________
How much per (day) (week) (month):__________________Quit:__________________ago. |
22. Alcohol consumption: Do you currently consume alcoholic beverages? ( ) No ( ) Yes: (Please indicate what product(s) you consume): (beer) (wine) (spirits). How much per (day) (week) (month):_____________
How long:_______________________________ |
|
23. Do you have a history of depression? ( ) No ( ) Yes: please explain________________
___________________________________________________________________________
Are you currently receiving therapy for your depression? ( ) No ( ) Yes |
| Are you currently taking prescribed medication for depression? ( ) No ( ) Yes: (Please list_______________________________________________________________________) |
| 24. Do you have a history of other emotional or psychiatric problems? ( ) No ( ) Yes: (Please explain:_____________________________________________________________________) |
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