Please print this survey and share your answers with your physician
This survey is reprinted from www.UrologyChannel.com.
Male Sexual Dysfunction Evaluation

1. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

1. Did not attempt intercourse
2. Extremely difficult
3. Very difficult
4. Difficult
5. Slightly difficult
6. Not difficult
   

2. How do you rate your confidence that you could get and keep an erection?

1. Very low
2. Low
3. Moderate
4. High
5. Very high

3. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?

1. No sexual activity
2. Almost never or never
3. A few times
4. Sometimes
5. Most times
6. Almost always
   

4. When you attempted sexual intercourse, how often was it satisfactory for you?

1. Did not attempt intercourse
2. Almost never or never
3. A few times
4. Sometimes
5. Most times
6. Almost always
   

5. During sexual intercourse, how often were you able to maintain your erection following penetration?

1. Did not attempt intercourse
2. Almost never or never
3. A few times
4. Sometimes
5. Most times
6. Almost always

6. During masturbation, how difficult is it to maintain your erection until ejaculation?

1. Did not attempt masturbation
2. Extremely difficult
3. Very difficult
4. Difficult
5. Slightly difficult
6. Not difficult