| Name:________________________________ |
|
Date:________________________________ |
 |
| (Write the number that best describes your erectile function for the past 4 weeks in the spaces provided.) |
|
Over the past four weeks:
1. How often were you able to get an erection during sexual activity? _______ |
|
0 = No sexual activity
1 = Almost never/never
2 = A few times (much less than half the time)
3 = Sometimes (about half the time)
4 = Most times (much more than half the time)
5 = Almost always/always |
|
| 2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration? _______ |
|
0 = No sexual activity
1 = Almost never/never
2 = A few times (much less than half the time)
3 = Sometimes (about half the time)
4 = Most times (much more than half the time)
5 = Almost always/always |
|
| 3. When you attempted sexual intercourse, how often were you able to penetrate (enter) your partner? _______ |
|
0 = Did not attempt intercourse
1 = Almost never/never
2 = A few times (much less than half the time)
3 = Sometimes (about half the time)
4 = Most times (much more than half the time)
5 = Almost always/always |
|
| 4. During intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? _______ |
|
0 = Did not attempt intercourse
1 = Almost never/never
2 = A few times (much less than half the time)
3 = Sometimes (about half the time)
4 = Most times (much more than half the time)
5 = Almost always/always |
|
| 5. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? _______ |
|
0 = Did not attempt intercourse
1 = Extremely difficult
2 = Very difficult
3 = Difficult
4 = Slightly difficult
5 = Not difficult |
|
| 6. How many times have you attempted sexual intercourse? _______ |
|
0 = No attempts
1 = One to two attempts
2 = Three to four attmepts
3 = Five to six attempts
4 = Seven to ten attempts
5 = Eleven or more attempts |
|
| 7. When you attempted sexual intercourse, how often was it satisfactory for you? _______ |
|
0 = Did not attempt intercourse
1 = Almost never/never
2 = A few times (much less than half the time)
3 = Sometimes (about half the time)
4 = Most times (much more than half the time)
5 = Almost always/always |
|
| 8. How much have you enjoyed sexual intercourse? _______ |
|
0 = No intercourse
1 = No enjoyment
2 = Not very enjoyable
3 = Fairly enjoyable
4 = Highy enjoyable
5 = Very highly enjoyable |
|
| 9. When you had sexual stimulation or intercourse, how often did you ejaculate? _______ |
|
0 = No sexual stimulation/intercourse
1 = Almost never/never
2 = A few times (much less than half the time)
3 = Sometimes (about half the time)
4 = Most times (much more than half the time)
5 = Almost always/always |
|
| 10. When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax? _______ |
|
0 = No sexual stimulation/intercourse
1 = Almost never/never
2 = A few times (much less than half the time)
3 = Sometimes (about half the time)
4 = Most times (much more than half the time)
5 = Almost always/always |
|
| 11. How often have you felt sexual desire? _______ |
|
1 = Almost never/never
2 = A few times (much less than half the time)
3 = Sometimes (about half the time)
4 = Most times (much more than half the time)
5 = Almost always/always |
|
| 12. How would you rate your sexual desire? _______ |
|
1 = Very low/none at all
2 = Low
3 = Moderate
4 = High
5 = Very high |
|
| 13. How satisfied have you been with your overall sex life? _______ |
|
1 = Very dissatisfied
2 = Moderately dissatisfied
3 = About equally satisfied and dissatisfied
4 = Moderately satisfied
5 = Very satisfied |
|
| 14. How satisfied have you been with your sexual relationship with your partner? _______ |
|
1 = Very dissatisfied
2 = Moderately dissatisfied
3 = About equally satisfied and dissatisfied
4 = Moderately satisfied
5 = Very satisfied |
|
| 15. How would you rate your confidence that you could get and keep an erection? _______ |
|
1 = Very low
2 = Low
3 = Moderate
4 = High
5 = Very high |
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