Sexual Performance Assessment
Each question has five possible responses. Select the number that best describes your own situation for the last 4 weeks. Select only one answer for each question.
Name
First Name
Your email (COMPLETELY CONFIDENTIAL)
*
example@example.com
1. How do you rate your confidence that you could get and keep an erection during intercourse?
*
Very Low
Low
Moderate
High
Very High
1. How do you rate your confidence that you could get and keep an erection during intercourse? Answer Score:
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
*
Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (more than half the time)
Almost always or always
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)? Answer Score:
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
*
Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (more than half the time)
Almost always or always
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? Answer Score:
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
*
Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? Answer Score:
5. When you attempted sexual intercourse, how often was it satisfactory for you?
*
Almost never or never
A few times (much less than half the time)
Sometimes (about half the time)
Most times (more than half the time)
Almost always or always
5. When you attempted sexual intercourse, how often was it satisfactory for you? Answer Score:
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Your Score
confidential
Total
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