These questions ask about the effects that your erection problems have had on your sex life over the past six months. Please try to answer the questions as honestly and as clearly as you are able. Your answers will help your doctor to choose the most effective treatment suited to your condition.


1. In the past 6 months, how do you rate your confidence that you could get and keep an erection?

2. In the past 6 months, when you had erections with sexual stimulation, how often were your erections hard enough for penetration?

3. In the past 6 months, during sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?

4. In the past 6 months, how difficult was it to maintain your erection to completion of intercourse?

5. In the past 6 months, when you attempted sexual intercourse, how often was it satisfactory for you?