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Patient Questionnaire

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  • Sexual activity includes intercourse caressing foreplay & masturbation.
  • Sexual Intercourse is defined as sexual penetration of your partner.
  • Sexual Stimulation includes situation such as foreplay, erotic pictures etc.
  • Ejaculation is the ejection of semen from the penis (or the feeling of this).
  • Orgasm is the fulfilment or climax following sexual stimulation or intercourse.

How often were you able to get an erection during sexual activity?

When you had erections with sexual stimulation, how often were your erections hard enough for penetration?

When you attempted intercourse, how often were you able to penetrate (enter) your partner?

During sexual intercourse, how often were you 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?

How many times have you attempted sexual intercourse?

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

How much have you enjoyed sexual intercourse?

When you had sexual stimulation or intercourse, how often did you ejaculate?

When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax?

How often have you felt sexual desire?

How would you rate your level of sexual desire?

How satisfied have you been with your overall sex life?

How satisfied have you been with your sexual relationship with your partner?

How do you rate your confidence that you could get and keep an erection?

Personal Info

How do you rate your confidence that you could get and keep an erection?

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