Erectile Dysfunction Questionnaire

Personal Data

First Name *

Middle Name

Last Name *

Email Address *

Phone

Date of Birth *

Referring Physician

Referring Physician Specialty

Primary Care Physician

Name

Phone/Fax

Street Address

Apartment, suite, etc

City

State/Province

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Patient History

Age

Approximate Duration of Problem

Onset of problem was:GradualSudden

If sudden, was it related in onset to:SurgeryNew medicationLife eventPenile injury

Present Sexual Function

Over 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/always

Over 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/always

When 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/always

During 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/always

When 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/always

What 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 erection

Do you have an active sexual partner at this time?YesNo

Can you achieve an orgasm?YesNo

Can you ejaculate normally?YesNo

Do you have premature ejaculation?YesNo

Do you think there is an emotional cause?YesNo

Do you experience any pain with erections?YesNo

Are or were your erections abnormally bent?YesNo

If so, which direction is it bent?YesNo

How many degrees is the bend?

Have you noted any change in the bend during the past six months?YesNo

Previous Evaluation

Have you had your testosterone level measured?YesNo

If so, what were the results?NormalAbnormalDon't Know

Have you ever received a penile injection?YesNo

If so, did it produce a full erection?YesNo

Have you undergone a penile blood flow study?YesNo

If so, what were the results?YesNo

Have you undergone testing of erections during sleep?YesNo

If so, what were the results?YesNo

Previous Treatment

Have you tried Viagra, Levitra or Cialis?YesNo

Did Viagra work to your satisfaction?YesNo

Have you tried MUSE?YesNo

Did MUSE produce a satisfactory erection?YesNo

Do you like using MUSE?YesNo

Have you tried injection therapy?YesNo

Did the injections produce a satisfactory erection?YesNo

Do you like doing injections?YesNo

Did the injections produce a satisfactory erection?YesNo

Did it work?YesNo

Do you like the vacuum device?YesNo

Have you tried any other treatments? What were they?

Risk Factors for Erectile Dysfunction

Have you ever injured your penis?YesNo

Has your penis ever been forcibly bent while erect?YesNo

Have you had a straddle injury?YesNo

Do you ride a bicycle regularly?YesNo

Have you ever smoked cigarettes regularly?YesNo

Do you currently smoke?YesNo

Have you ever had problems with excessive alcohol drinking?YesNo

Have you injured your spinal cord?YesNo

Have you had your prostate removed for cancer?YesNo

Have you undergone radiation therapy for prostate cancer?YesNo

Have you had prostate surgery (TURP) for benign prostatic growth?YesNo

How many children have you fathered?

Past Medical History

Are you being treated for diabetes mellitus?YesNo

If so, which treatment method are you using to control your sugar?YesNo

Are you being treated for high blood pressure?YesNo

Are you being treated for elevated blood cholesterol level?YesNo

Do you have heart disease?YesNo

Have you ever had a stroke?YesNo

Have you been told that you have hardening of the arteries?YesNo

Are you or have you been treated for depression?YesNo

Other medical illnesses:

Past surgeries:

List medications:

Do you take aspirin regularly?YesNo

List any medications that you are allergic to:

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Primary Care Physician

Patient History

Present Sexual Function

Previous Evaluation

Previous Treatment

Risk Factors for Erectile Dysfunction

Past Medical History

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