Erectile Dysfunction Patient Questionnaire

ERECTILE DYSFUNCTION

Version 06.08.23
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
1. Are you currently receiving treatment for erectile dysfunction?*

YesNoDon’t know
2. What kind of sexual activities do you engage in? (May select all that apply)*

MasturbationOral sexVaginal penetrationAnal penetration
3. Do you watch pornography?*

YesNo
4. Do you feel that the amount of pornography you watch may be problematic?*

YesNo
5. What treatment are you currently administering? (May select more than one)*

PillsVacuum deviceIntraurethral suppositoryInjectionsPenile prosthesisNone of the above
6. For how many years have you been treated for erectile dysfunction?*
7. How satisfied are you with your current treatment?*

Very dissatisfiedSomewhat satisfiedSomewhat dissatisfiedVery satisfiedNeither satisfied nor dissatisfied
IEEF Questionnaire

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.

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 situations 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
1. How often were you able to get an erection during sexual activity?*

0 No sexual activity1 Almost never or never2 A few times (less than half the time)3 Sometimes (about half the time)4 Most times (more than half the time)5 Almost always or always
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration?*

0 No sexual activity1 Almost never or never2 A few times (less than half the time)3 Sometimes (about half the time)4 Most times (more than half the time)5 Almost always or always
3. When you attempted intercourse, how often were you able to penetrate (enter) your partner?*

0 - Did not attempt intercourse3 - Sometimes (about half the time)1 - Almost never or never4 - Most times (more than half the time))2 - A few times (less than half the time)5 - Almost always or always
4. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?*

0 - Did not attempt intercourse3 - Sometimes (about half the time)1 - Almost never or never4 - Most times (more than half the time))2 - A few times (less than half the time)5 - Almost always or always
5. During sexual intercourse, how difficult was it to maintain your erection to completion ofintercourse?*

0 - Did not attempt intercourse1 - Extremely difficult2 - Very difficult3 - Difficult4 - Slightly difficult5 - Not difficult
6. How many times have you attempted sexual intercourse?*

0 - No attempts1 - One to two attempts2 - Three to four attempts3 - Five to six attempts4 - Seven to ten attempts5 - Eleven or more attempts
7. When you attempted sexual intercourse, how often was it satisfactory for you?*

0 - Did not attempt intercourse3 - Sometimes (about half the time)1 - Almost never or never4 - Most times (more than half the time)2 - A few times (less than half the time)5 - Almost always or always
8. How much have you enjoyed sexual intercourse?*

0 - No intercourse1 - No enjoyment at all2 - Fairly enjoyable3 - Highly enjoyable4 - Very highly enjoyable
9. When you had sexual stimulation or intercourse, how often did you ejaculate?*

0 - Did not attempt intercourse3 - Sometimes (about half the time)1 - Almost never or never4 - Most times (more than half the time)2 - A few times (less than half the time)5 - Almost always or always
10.When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax?*

1 - Almost never or never4 - Most times (more than half the time)2 - A few times (less than half the time)5 - Almost always or always3 - Sometimes (about half the time)
11.How often have you felt sexual desire?*

1 - Almost never or never4 - Most times (more than half the time)2 - A few times (less than half the time)5 - Almost always or always3 - Sometimes (about half the time)
12.How would you rate your level of sexual desire?*

1 - Very low or none at all2 - Low3 - Moderate4 - High5 - Very high
13.How satisfied have you been with your overall sex life?*

1 - Very dissatisfied2 - Moderately dissatisfied3 - Equally satisfied & dissatisfied4 - Moderately satisfied5 - Very satisfied
14.How satisfied have you been with your sexual relationship with your partner?*

1 - Very dissatisfied2 - Moderately dissatisfied3 - Equally satisfied & dissatisfied4 - Moderately satisfied5 - Very satisfied
15.How do you rate your confidence that you could get and keep an erection?*

1 - Very low or none at all2 - Low3 - Moderate4 - High5 - Very high
Patient or Representative Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

ERECTILE DYSFUNCTION

OVER THE PAST 4 WEEKS