Urological Associates of Western Colorado (Sexual Health)

Sexual Health

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		Provider Name

Patient Information

*Please provide the patient's full legal name as it appears on their driver's license, state identification card, or government issued identification card.

Sexual Health

* Required Information

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?

Very low

Low

Moderate

High

Very high

*When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?

No sexual activity

Almost never or 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 or always

*During sexual intercourse, how often were your able to maintain your erection after you had penetrated (entered) your partner?

Did not attempt intercourse

Almost never or 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 or always

*During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

Did not attempt intercourse

Extremely difficult

Very difficult

Difficult

Slightly difficult

Not difficult

*When you attempted sexual intercourse, how often was it satisfactory to you?

Did not attempt intercourse

Almost never or 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 or always

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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 749

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