Each question has several possible responses.

Please select the response that best describes your own situation.

 

Over the past 6 months:

 
How do you rate your confidence that you could get and keep and erection?
 
 
 
 
 
 
 
 
 
 
 
When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
 
 
 
 
 
 
 
 
 
 
 
 
 
During sexual intercourse, how often were your able to maintain your erection after you had penetrated (entered) your partner?
 
 
 
 
 
 
 
 
 
 
 
 
 
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
 
 
 
 
 
 
 
 
 
 
 
 
 
When you attempted sexual intercourse, how often was it satisfactory to you?
 
 
 
 
 
 
 
 
 
 
 
 
 

IMPORTANT: Please do not use the 'BACK' button on your browser while completing your history forms.
 
Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 749
This form is meant to be submitted online. Please return to the form on your computer, answer all questions, and click the ‘Submit’ button when completed.