How do you rate your confidence that you could get and keep an erection during intercourse?
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Very Low
Low
Moderate
High
Very High
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When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
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Almost Never or Never
A Few Times
Sometimes
Most Times
Almost Always or Always
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During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
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Almost Never or Never
A Few Times
Sometimes
Most Times
Almost Always or Always
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During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?s
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Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult
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When you attempted sexual intercourse, how often was it satisfactory for you?
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Almost Never or Never
A Few Times
Sometimes
Most Times
Almost Always or Always
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Name
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First Name
Last Name
Email
*
example@example.com
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