International Index of Erectile Dysfunction 15

PATIENT NAME:

DOB:

TODAY'S DATE:

Date

The first five questions refer to erectile function.

1. Over the last month, how often were you able to get an erection during sexual activity?

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. Over the last month, when you had erections with sexual stimulations, how often were your erections hard enough for penetration?

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. Over the last month, when you attempted intercourse, how often were you able to penetrate your partner?

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

4. Over the last month, during sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?

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

5. Over the last month, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

No Sexual Activity Extremely difficult Very difficult Difficult Slightly difficult Not difficult

The next three questions refer to satisfaction with intercourse.

6. Over the last month, how many times have you attempted sexual intercourse?

No attempts 1-2 times 3-4 times 5-6 times 7-10 times 11-20 times

7. Over the last month, when you attempted sexual intercourse how often was it satisfactory for you?

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

8. Over the last month, how much have you enjoyed sexual intercourse?

No intercourse Very highly enjoyable Highly enjoyable Fairly enjoyable Not very enjoyable No enjoyment

The next two questions refer to orgasmic function.

9. Over the last month, when you had sexual stimulation or intercourse, how often did you ejaculate?

No sexual stimulation/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. Over the last month, when you had sexual stimulation or intercourse, how often did you have the feeling of orgasm (with or without ejaculation)?

No sexual stimulation/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

The next two questions ask about sexual desire. In this context, sexual desire is defined as a feeling that may include wanting to have a sexual experience (for example, masturbation or sexual intercourse), thinking about having sex, or feeling frustrated due to lack of sex.

11. Over the last month, how often have you felt sexual desire?

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. Over the last month, how would you rate your level of sexual desire?

Very high High Moderate Low Very low or not at all

The next two questions refer to overall sexual satisfaction.

13. Over the last month, how satisfied have you been with your overall sex life?

Very satisfied Moderately satisfied About equally satisfied and dissatisfied Moderately dissatsfied Very dissatisfied

14. Over the last month, how satisfied have you been with your sexual relationship with your partner?

Very satisfied Moderately satisfied About equally satisfied and dissatisfied Moderately dissatsfied Very dissatisfied

The last questions refers to erectile function.

15. Over the last month, how do you rate your confidence that you can get and keep your erection?

Very high High Moderate Low Very low

Area	Questions	Score Range	Maximum Score	Your Score
Erectile Function	1-5 & 15	0-5	30
Orgasmic Function	9-10	0-5	10
Sexual Desire	11-12	1-5	10
Intercourse Satisfaction	6-8	0-5	15
Overall Satisfaction	13-14	1-5	10

SCORING:

1-10: Severe Erectile Dysfunction

11-16: Moderate dysfunction

17-21: Mild to moderate dysfunction

22-25: Mild dysfunction

26-30: No dysfunction

This information, including the questions, structure and completeness of the sample survey, is based on forms and/or scoring systems developed by independent organizations of relevance to the diagnosis and treatment of benign prostatic hyperplasia (BPH This material is not a substitute for a consultation or physical examination by a physician. Merit Medical disclaims any liability for the decisions a patient makes based on this information.

TOTAL

403728001A ID 071717

International Index of Erectile Dysfunction

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