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Patient Questionnaire

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?

No sexual activity.

Sometimes(about half the time)

Almost never or never

Most times(more than half the time)

A few times (less than half the time)

Almost always or always

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

No sexual activity.

Sometimes(about half the time)

Almost never or never

Most times(more than half the time)

A few times (less than half the time)

Almost always or always

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

Did not attempt intercourse

Sometimes(about half the time)

Almost never or never

Most times(more than half the time)

A few times (less than half the time)

Almost always or always

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

Did not attempt intercourse

Sometimes(about half the time)

Almost never or never

Most times(more than half the time)

A few times (less 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

Difficult

Extremely difficult

Slightly difficult

Very difficult

Not difficult

How many times have you attempted sexual intercourse?

Did not attempt intercourse

Five to six attempts

One to two attempts

Seven to ten attempts

Three to four attempts

Eleven or more attempts

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

Did not attempt intercourse

Sometimes(about half the time)

Almost never or never

Most times(more than half the time)

A few times (less than half the time)

Almost always or always

How much have you enjoyed sexual intercourse?

Did not attempt intercourse

Fairly enjoyable

No enjoyment at all

Highly enjoyable

Not very enjoyable

Very highly enjoyable

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

No sexual stimulation or intercourse

Sometimes(about half the time)

Almost never

Most times(more than half the time)

A few times (less than half the time)

Almost always or always

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

No sexual stimulation or intercourse

Sometimes(about half the time)

Almost never or never

Most times(more than half the time)

A few times (less than half the time)

Almost always or always

How often have you felt sexual desire?

No sexual desire

Sometimes(about half the time)

Almost never or never

Most times(more than half the time)

A few times (less than half the time)

Almost always or always

How would you rate your level of sexual desire?

No sexual desire

Moderate

Very low

High

Low

Very high

How satisfied have you been with your overall sex life?

No satisfaction

Equally satisfied & dissatisfied

Very dissatisfied

Moderately satisfied

Moderately dissatisfied

Very Satisfied

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

No satisfaction

Equally satisfied & dissatisfied

Very dissatisfied

Moderately satisfied

Moderately dissatisfied

Very Satisfied

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

No confidence

Moderate

Very low

High

Low

Very high

Personal Info

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

+1(480) 245-4593
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14301 N 87th St., Ste 308
Scottsdale, AZ 85260

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