Erectile Dysfunction Patient Questionnaire

  • ERECTILE DYSFUNCTION

    Version 06.08.23
  • Date of Birth:*
     - -
  • Format: (000) 000-0000.
  • 1. Are you currently receiving treatment for erectile dysfunction?*
  • 2. What kind of sexual activities do you engage in? (May select all that apply)*
  • 3. Do you watch pornography?*
  • 4. Do you feel that the amount of pornography you watch may be problematic?*
  • 5. What treatment are you currently administering? (May select more than one)*
  • 7. How satisfied are you with your current treatment?*

  • 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?*
  • 2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration?*
  • 3. When you attempted intercourse, how often were you able to penetrate (enter) your partner?*
  • 4. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?*
  • 5. During sexual intercourse, how difficult was it to maintain your erection to completion ofintercourse?*
  • 6. How many times have you attempted sexual intercourse?*
  • 7. When you attempted sexual intercourse, how often was it satisfactory for you?*
  • 8. How much have you enjoyed sexual intercourse?*
  • 9. When you had sexual stimulation or intercourse, how often did you ejaculate?*
  • 10.When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax?*
  • 11.How often have you felt sexual desire?*
  • 12.How would you rate your level of sexual desire?*
  • 13.How satisfied have you been with your overall sex life?*
  • 14.How satisfied have you been with your sexual relationship with your partner?*
  • 15.How do you rate your confidence that you could get and keep an erection?*
  • Date*
     - -
  • Should be Empty: