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Sexual Impotence Screen

Sexual health is an important part of an individual's physical and emotional health.  
Erectile dysfunction, also known as impotence is one type of a very common medical condition. This questionnaire is designed to help identify if you may be experiencing this condition. If you are, you need to discuss this with your doctor for treatment options.
Answer all questions.  
Skipping any question will not give the correct result.
Choose the response that applies to you most of the time in the past couple of months.

  1 How do you rate your confidence in getting and keeping an erection?

very low       
low       
moderate       
high       
very high

  2 When you have erections with sexual stimulation, how often are your erections hard enough for penetration?

no sexual action       
almost never or never     
less than half the time
half the time             
almost always or always

  3 During sexual intercourse how often were you able to maintain erection after penetration?

did not attempt intercourse       
almost never or never
less than half the time              
half the time          
almost always or always

  4 During sexual intercourse how difficult was it to maintain your erection to completion of intercourse?

did not attempt intercourse           
extremely difficult     
very difficult   
difficult                
slightly difficult                    
not difficult 
  5 When you attempted sexual intercourse, how often was it satisfactory for you?

did not attempt intercourse       
almost never     
less than half the time
half the time         
more than half the time          
almost always