erectile dysfunction Self Assessment Welcome to your erectile dysfunction Self Assessment Your Name Your Email Phone No. 1. How often have you managed to get an erection during sexual activity in the last month? Please select your answerno sexual activityalmost always or alwaysmost times (much more than half the time)sometimes (about half the time)a few times (much less than half the time)almost never or never None 2. When you had erections with sexual stimulation in the last month, how often were your erections hard enough for penetration? Please select your answerno sexual activityalmost always or alwaysmost times (much more than half the time)sometimes (about half the time)a few times (much less than half the time)almost never or never 3. When you attempted sexual intercourse in the last month, how often were you able to penetrate your partner? Please select your answerno attemptalmost always or alwaysmost times (much more than half the time)sometimes (about half the time)a few times (much less than half the time)almost never or never 4. During sexual intercourse in the last month, how often were you able to maintain your erection after you had penetrated your partner? Please select your answerno attemptalmost always or alwaysmost times (much more than half the time)sometimes (about half the time)a few times (much less than half the time)almost never or never 5. During sexual intercourse in the last month, how difficult was it to maintain your erection to completion of intercourse? Please select your answerno attemptextremely difficultvery difficultdifficultslightly difficultnot difficult 6. How often have you attempted sexual intercourse in the last month? Please select your answerno attempts1-2 attempts2-3 attempts5-6 attempts7-10 attempts11-20 attempts 7. When you attempted sexual intercourse, how often was it satisfactory for you? Please select your answerno attemptalmost always or alwaysmost times (much more than half the time)sometimes (about half the time)a few times (much less than half the time)almost never or never 8. How much did you like your sexual intercourse in the last month? Please select your answerno sexual intercoursevery well likedwell likedit was all right.not much likednot liked 9. When you have had sexual stimulation or intercourse during the last month, how often have you ejaculated? Please select your answerno sexual stimulation or intercoursealmost always or alwaysmost times (much more than half the time)sometimes (about half the time)a few times (much less than half the time)almost never or never 10. When you have had sexual stimulation or intercourse during the last month, how often have you had the feeling of orgasm (with or without ejaculation)? Please select your answerno sexual stimulation or intercoursealmost always or alwaysmost times (much more than half the time)sometimes (about half the time)a few times (much less than half the time)almost never or never 11. How often did you feel sexual desire during the last month? Please select your answeralmost always or alwaysmost times (much more than half the time)sometimes (about half the time)a few times (much less than half the time)almost never or never 12. How high would you rate your sexual desire during the last month? Please select your answervery highhighmoderatelowvery low to no desire 13. How satisfied have you been with your overall sex life during the last month? Please select your answervery satisfiedquite satisfiedabout equally satisfiedquite unsatisfiedvery unsatisfied 14. How satisfied have you been with your sexual relationship with your partner during the last month? Please select your answervery satisfiedquite satisfiedabout equally satisfiedquite unsatisfiedvery unsatisfied 15. How do you rate your confidence with regard to the last month that you could get and keep an erection? Please select your answervery highhighmoderatelowvery low Time's up
