• Please complete the following form only if instructed by our office staff.
  • Date of Surgery
     - -
    2 digit month, 2 digit day, 4 digit year
  • How do you rate your confidence that you could get and keep an erection?
  • When you had erections with sexual stimulation, how often were your erections hard enough for penetration?*
  • During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?*
  • During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?*
  • When you attempted sexual intercourse, how often was it satisfactory for you?*

  • TOTAL SCORE: ______________

    NOTES: 

     

     

     

     

     

     

     

  • Should be Empty: