Erectile Dysfunction Quiz

Erectile Dysfunction Quiz

Confidential & Discreet
These questions ask about the effects your erection issues have had on your sex life OVER THE PAST 4 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, and 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 fulfillment or climax following sexual stimulation or intercourse
*Over the past 4 weeks, please check only one box.
Name*

First NameLast Name
Phone & Email*

Phone NumberEmail Address
1. How often were you able to get an erection during sexual activity?:*

No sexual activityAlmost never or neverA few times (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?:*

No sexual activityAlmost never or neverA few times (less than half the time)Sometimes (about half the time)Most times (more than half the time)Almost always or always
3. When you attempted intercourse, how often were you able to achieve penetration?:*

Did not attempt intercourseAlmost never or neverA few times (less than half the time)Sometimes (about half the time)Most times (more than half the time)Almost always or always
4. During sexual intercourse, how often were you able to maintain your erection during penetration?:*

Did not attempt intercourseAlmost never or neverA few times (less than half the time)Sometimes (about half the time)Most times (more than half the time)Almost always or always
5. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?:*

Did not attempt intercourseExtremely difficultVery difficultDifficultSlightly difficultNot difficult
6. How many times have you recently attempted intercourse?:*

01-23-45-67-1011 or more
7. When you attempted sexual intercourse, how often was it satisfactory for you?:*

Did not attempt intercourseAlmost never or neverA few times (less than half the time)Sometimes (about half the time)Most times (more than half the time)Almost always or always
8. Overall, how much have you enjoyed sexual stimulation or intercourse?:*

No stimulation or intercourseNo enjoyment at allNot very enjoyableFairly enjoyableHighly enjoyableVery highly enjoyable
9. When you had sexual stimulation or intercourse, how often did you ejaculate?:*

No sexual stimulation or intercourseAlmost never or neverA few times (less than half the time)Sometimes (about half the time)Most times (more than half the time)Almost always or always
10. When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax?:*

No sexual stimulation or intercourseAlmost never or neverA few times (less than half the time)Sometimes (about half the time)Most times (more than half the time)Almost always or always
11. How often have you felt sexual desire recently?:*

Almost never or neverA few times (less than half the time)Sometimes (about half the time)Most times (more than half the time)Almost always or always
12. How would you rate your recent level of sexual desire?:*

None at allVery lowLowModerateHighVery high
13. How satisfied have you been with your recent overall sex life?:*

Very dissatisfiedModerately dissatisfiedEqually satisfied & dissatisfiedModerately satisfiedVery satisfied
14. How satisfied have you been with your sexual relationship with your partner?:*

Very dissatisfiedModerately dissatisfiedEqually satisfied & dissatisfiedModerately satisfiedVery satisfied
15. How would you rate your confidence that you could get & keep an erection?:*

Very lowLowModerateHighVery high
Total point is
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform