- 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