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Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Email

How do you rate your confidence that you could get and keep an erection?

When you had erections with sexual stimulation, how often were they hard enough for penetration?

During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

When you attempted sexual intercourse, how often was it satisfactory for you?

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