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 answer no sexual activity almost always or always most 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 2. When you had erections with sexual stimulation in the last month, how often were your erections hard enough for penetration? Please select your answer no sexual activity almost always or always most 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 answer no attempt almost always or always most 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 answer no attempt almost always or always most 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 answer no attempt extremely difficult very difficult difficult slightly difficult not difficult 6. How often have you attempted sexual intercourse in the last month? Please select your answer no attempts 1-2 attempts 2-3 attempts 5-6 attempts 7-10 attempts 11-20 attempts 7. When you attempted sexual intercourse, how often was it satisfactory for you? Please select your answer no attempt almost always or always most 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 answer no sexual intercourse very well liked well liked it was all right. not much liked not liked 9. When you have had sexual stimulation or intercourse during the last month, how often have you ejaculated? Please select your answer no sexual stimulation or intercourse almost always or always most 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 answer no sexual stimulation or intercourse almost always or always most 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 answer almost always or always most 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 answer very high high moderate low very low to no desire 13. How satisfied have you been with your overall sex life during the last month? Please select your answer very satisfied quite satisfied about equally satisfied quite unsatisfied very unsatisfied 14. How satisfied have you been with your sexual relationship with your partner during the last month? Please select your answer very satisfied quite satisfied about equally satisfied quite unsatisfied very 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 answer very high high moderate low very low Time's up
