Erectile Dysfunction Questionnaire

Personal Data

 
Wilmington, NC
Goldsboro, NC
 
 

Patient History

 
 
Gradual
Sudden
 
Surgery
New medication
Life event
Penile injury

Present Sexual Function

 
did not engage in any sexual activity
almost 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/always
 
did not engage in any sexual activity
almost 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/always
 
did not attempt intercourse
almost 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/always
 
unable to attempt intercourse
almost 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/always
 
unable to attempt intercourse
almost 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/always
 
very low/none at all
low
moderate
high
very high
 
none at all
partial (less than half)
partial (better than half)
full erection
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
up
down
left
right
 
 
yes
no

Previous Evaluation

 
yes
no
 
Normal
Abnormal
Don't Know
 
yes
no
 
yes
no
 
yes
no
 
Normal
Abnormal
Don't Know
 
yes
no
 
Normal
Abnormal
Don't Know

Previous Treatment

 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no

Risk Factors for Erectile Dysfunction

 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 

Past Medical History

 
yes
no
 
diet
pills
pills
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no
 
yes
no

Family History

 
High blood pressure
Diabetes
Heart disease
Prostate cancer
Peyronie's disease
Cancer
 

 

*Individual results may vary.