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PATIENT FORMS
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PATIENT FORMS
CONTACT

Name*

Last name*

Symptoms observed whilst using medications*

Yes

Which medications? (Choose multiple if relevant)

Viagra / Sildenafil

Cialis / Tadalafil

Spedra / Avanafil

Caverject / Alprostadil

Bimix

Trimix

NIL

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

Very Low (1)

Low (2)

Moderate (3)

High (4)

Very High (5)

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

No sexual activity (0)

Almost never or never (1)

A few times (much less than half the time) (2)

Sometimes (about half the time) (3)

Most times (much more than half the time) (4)

Almost always or always (5)

During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?*

Did not attempt intercourse (0)

Almost never or never (1)

A few times (much less than half the time) (2)

Sometimes (about half the time) (3)

Most times (much more than half the time) (4)

Almost always or always (5)

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

Did not attempt intercourse (0)

Extremely difficult (1)

Very difficult (2)

Difficult (3)

Slightly difficult (4)

Not difficult (5)

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

Did not attempt intercourse (0)

Almost never or never (1)

A few times (much less than half the time) (2)

Sometimes (about half the time) (3)

Most times (much more than half the time) (4)

Almost always or always (5)

Answer questions based on the symptoms you have observed over the past 6 months. Choose the answer that most closely approximates your belief.

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