Erectile Dysfunction QuestionnairePersonal DataFirst Name *Middle NameLast Name *Email Address *PhoneDate of Birth *Referring PhysicianReferring Physician SpecialtyPrimary Care PhysicianPrimary Care PhysicianNamePhone/FaxStreet AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodePatient HistoryAgeApproximate Duration of ProblemOnset of problem was:GradualSuddenIf sudden, was it related in onset to:SurgeryNew medicationLife eventPenile injuryPresent Sexual FunctionOver the past 30 days, how often have you had partial or full erections when you were sexually stimulated in any way?did not engage in any sexual activityalmost nevera few times (much less than half the time)sometimes (about half the time)most times (much more than half the time)almost always/alwaysOver the past 30 days, when you had erections, how often were the erections firm enough to have sexual relations?did not engage in any sexual activityalmost nevera few times (much less than half the time)sometimes (about half the time)most times (much more than half the time)almost always/alwaysWhen you attempted sexual intercourse, how often were you able to penetrate (enter) your partner?did not attempt intercoursealmost nevera few times (much less than half the time)sometimes (about half the time)most times (much more than half the time)almost always/alwaysDuring sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?unable to attempt intercoursealmost nevera few times (much less than half the time)sometimes (about half the time)most times (much more than half the time)almost always/alwaysWhen you attempted sexual intercourse, how often was your erection satisfactory in your opinion?unable to attempt intercoursealmost nevera few times (much less than half the time)sometimes (about half the time)most times (much more than half the time)almost always/alwaysHow would you rate your level of sexual desire?very low/none at alllowmoderatehighvery highWhat is the quality of the best erection you have experienced during the night or upon awakening in the morning during the past month?none at allpartial (less than half)partial (better than half)full erectionDo you have an active sexual partner at this time?YesNoCan you achieve an orgasm?YesNoCan you ejaculate normally?YesNoDo you have premature ejaculation?YesNoDo you think there is an emotional cause?YesNoDo you experience any pain with erections?YesNoAre or were your erections abnormally bent?YesNoIf so, which direction is it bent?YesNoHow many degrees is the bend?Have you noted any change in the bend during the past six months?YesNoPrevious EvaluationHave you had your testosterone level measured?YesNoIf so, what were the results?NormalAbnormalDon't KnowHave you ever received a penile injection?YesNoIf so, did it produce a full erection?YesNoHave you undergone a penile blood flow study?YesNoIf so, what were the results?YesNoHave you undergone testing of erections during sleep?YesNoIf so, what were the results?YesNoPrevious TreatmentHave you tried Viagra, Levitra or Cialis?YesNoDid Viagra work to your satisfaction?YesNoHave you tried MUSE?YesNoDid MUSE produce a satisfactory erection?YesNoDo you like using MUSE?YesNoHave you tried injection therapy?YesNoDid the injections produce a satisfactory erection?YesNoDo you like doing injections?YesNoDid the injections produce a satisfactory erection?YesNoDid it work?YesNoDo you like the vacuum device?YesNoHave you tried any other treatments? What were they?Risk Factors for Erectile DysfunctionHave you ever injured your penis?YesNoHas your penis ever been forcibly bent while erect?YesNoHave you had a straddle injury?YesNoDo you ride a bicycle regularly?YesNoHave you ever smoked cigarettes regularly?YesNoDo you currently smoke?YesNoHave you ever had problems with excessive alcohol drinking?YesNoHave you injured your spinal cord?YesNoHave you had your prostate removed for cancer?YesNoHave you undergone radiation therapy for prostate cancer?YesNoHave you had prostate surgery (TURP) for benign prostatic growth?YesNoHow many children have you fathered?Past Medical HistoryAre you being treated for diabetes mellitus?YesNoIf so, which treatment method are you using to control your sugar?YesNoAre you being treated for high blood pressure?YesNoAre you being treated for elevated blood cholesterol level?YesNoDo you have heart disease?YesNoHave you ever had a stroke?YesNoHave you been told that you have hardening of the arteries?YesNoAre you or have you been treated for depression?YesNoOther medical illnesses:Past surgeries:List medications:Do you take aspirin regularly?YesNoList any medications that you are allergic to:Do you have a family history of:Do you have a family history of:High blood pressureDiabetesHeart diseaseProstate cancerPeyronie's diseaseCancerSend Form