INTERNATIONAL INDEX OF ERECTILE FUNCTION PART 2

INTERNATIONAL INDEX OF ERECTILE FUNCTION

Patient Questionnaire
NAME

First NameLast Name
Age
Date

MonthDayYear
These questions ask about the effects that your erection problems have had on your sex life over the last four weeks. Please try to answer the questions as honestly and as clearly as you are able. Your answers will help your doctor to choose the most effective treatment suited to your condition. In answering the questions, the following definitions apply:
-sexual activity includes intercourse, caressing, foreplay & masturbation

-sexual intercourse is defined as sexual penetration of your partner

-sexual stimulation includes situation such as foreplay, erotic pictures etc.

-ejaculation is the ejection of semen from the penis (or the feeling of this)

-orgasm is the fulfilment or climax following sexual stimulation or intercourse
* OVER THE PAST 4 WEEKS

CHECK ONE BOX ONLY
Q6. How many times have you attempted sexual intercourse?
No attemptsOne to two attemptsThree to four attemptsFive to six attemptsFive to six attemptsEleven or more attempts
Q7. When you attempted sexual intercourse, how often was it satisfactory for you?
Did not attempt intercourseAlmost never or neverA few times (less than half the time)Sometimes (about half the time)Most times (more than half the time)Almost always or always
Q8. How much have you enjoyed sexual intercourse?
No intercourseNo enjoyment at allNot very enjoyableFairly enjoyableHighly enjoyableVery highly enjoyable
Q9. When you had sexual stimulation or intercourse, how often did you ejaculate?
No sexual stimulation or intercourseAlmost never or neverA few times (less than half the time)Sometimes (about half the time)Most times (more than half the time)Almost always or always
Q10. When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax?
Almost never or neverA few times (less than half the time)Sometimes (about half the time)Most times (more than half the time)Almost always or always
Q11. How often have you felt sexual desire?
Almost never or neverA few times (less than half the time)Sometimes (about half the time)Most times (more than half the time)Almost always or always
Q12. How would you rate your level of sexual desire?
Very low or none at allLowModerateHighVery high
Q13. How satisfied have you been with your overall sex life?
Very dissatisfiedModerately dissatisfiedEqually satisfied & dissatisfiedModerately satisfiedVery satisfied
Q14. How satisfied have you been with your sexual relationship with your partner?
Very dissatisfiedModerately dissatisfiedEqually satisfied & dissatisfiedModerately satisfiedVery satisfied
Q15. How do you rate your confidence that you could get and keep an erection?
Very lowLowModerateHighVery high
Should be Empty: