Erectile Dysfunction Assessment
Please complete this confidential assessment to help evaluate your symptoms and factors related to erectile dysfunction.
Full Name
*
First Name
Last Name
Age
*
Email Address
*
example@example.com
How would you describe your general health?
*
Excellent
Good
Fair
Poor
Do you have any of the following conditions? (Select all that apply)
*
Diabetes
High blood pressure
Heart disease
High cholesterol
None of the above
Other
Do you currently take any medications?
*
Yes
No
Lifestyle factors
*
Rows
Never
Sometimes
Often
Always
Do you smoke?
1
2
3
4
Do you drink alcohol?
5
6
7
8
Do you exercise regularly?
9
10
11
12
Over the past 6 months, how often have you experienced difficulty achieving or maintaining an erection during sexual activity?
*
Never
Rarely (less than 25% of the time)
Sometimes (about half the time)
Most times (more than 75% of the time)
Always
Please rate the following aspects of your sexual function over the past 6 months:
*
Rows
Very Poor
Poor
Fair
Good
Very Good
Confidence in getting and keeping an erection
13
14
15
16
17
Satisfaction with sexual intercourse
18
19
20
21
22
Level of sexual desire
23
24
25
26
27
How much does erectile dysfunction affect your quality of life?
*
Not at all
1
2
3
4
5
6
7
8
9
Severely
10
1 is Not at all, 10 is Severely
Please provide any additional information or concerns you would like to share with your healthcare provider.
Submit Assessment
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