Erectile Dysfunction Assessment

1

Over the past 4 weeks, how often were you able to get an erection during sexual activity?* This field is required.

Never

Rarely

Sometimes

Most of the time

Always

2

During sexual activity, how confident were you that you could get and maintain an erection?* This field is required.

Not at all confident

Slightly confident

Moderately confident

Very confident

Extremely confident

3

When you had erections, how often were they firm enough for penetration?* This field is required.

Never

Rarely

Sometimes

Most of the time

Always

4

During sexual activity, how often were you able to maintain your erection to completion?* This field is required.

Never

Rarely

Sometimes

Most of the time

Always

5

How satisfied are you with your sexual performance?* This field is required.

Very dissatisfied

Dissatisfied

Neutral

Satisfied

Very satisfied

6

Score* This field is required.

5-7 (severe ED), 8-11 (moderate ED), 12-16 (mild to moderate ED), 17-21 (mild ED), 22-25 (no ED)

7

Email* This field is required.

example@example.com

8

First NameOptional

9

Phone NumberOptional only if you prefer we call.

Area Code

Phone Number

10

Best Time to Reach YouOptional

11

I agree to receive text messages from Bluff City Health & Wellness for follow-up and scheduling. Msg/data rates may apply. Reply STOP to opt out. See Privacy Policy.* This field is required.

YESNO