– EMERGENCY CONTACT –

Relationship to patient
ParentSignificant OtherSiblingChildFriendOther

– MEDICAL HISTORY –

What have you tried? (check all that apply)
ViagraCialisLevitraInjectionsVED/PumpTestosteroneGAINSwave

How firm are your natural erections? (scale of 1-100)

How frequently do you have morning erections?
DailyWeeklyMonthlyRarelyNever

List All Medical Conditions

List All Current Medications/Supplements

Surgical History

Social History
SingleDatingMarriedDivorcedWidowed

Do you smoke?
YesNo

Do you consume alcoholic beverages?
YesNo

Do you use marijuana, cocaine or other similar illegal drugs?
YesNo

– IIEF/SHIM INTERNATIONAL INDEX OF ERECTILE FUNCTION –

How do you rate your confidence that you could achieve and keep an erection?
1 – Never / Almost-never2 – Low3 – Moderate4 – High5 – Very High

When you had erections with sexual stimulation, how often were
your erections hard enough for penetration?
1 – Never / Almost never2 – A few times (much less than half the time3 – Sometimes (about half the time)4 – Most times (much more than half the time)5 – Almost always / Always

During sexual intercourse, how often were you able to maintain your
erection after you had penetrated (entered) your partner?
1 – Never / Almost never2 – A few times (much less than half the time3 – Sometimes (about half the time)4 – Most times (much more than half the time)5 – Almost always / Always

During sexual intercourse, how difficult was it to maintain your
erection to completion of intercourse?
1 – Extremely difficult2 – Very difficult3 – Difficult4 – Slightly Difficult5 – Not difficult

When you attempted sexual intercourse, how often was it satisfactory
for you?
1 – Never / Almost never2 – A few times (much less than half the time3 – Sometimes (about half the time)4 – Most times (much more than half the time)5 – Almost always / Always