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* 1. First Name

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* 2. Last Name

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* 3. Date of Birth

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* 4. Age

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* 5. Marital Status

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* 6. Email Address

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* 7. Phone Number

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* 8. Do you have problems obtaining, maintaining an erection or both?

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* 9. When did you notice a change in your sexual function (approximate year/month?

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* 10. Do you recall any significant events which occurred around the same time?

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* 11. Select One

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* 12. Circle the number that best describes the quality of your erections

  Erection - 1 Erection - 2 Erection - 3 Erection - 4 Erection - 5
Select

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* 13. Do you have an erection or semi erection in the morning before you urinate?

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* 14. Do you ever awaken at night and notice an erection or semi erection?

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* 15. Do other types of stimulus improve your erections such as masturbation, oral sex, erotic films, reading material?

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* 16. Are your erections ever firm enough for vaginal penetration?

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* 17. Do you ever notice any increase or decrease in your erections with position changes?

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* 18. Are you concerned about the appearance of your penis such as:

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* 19. When was the last time you had successful intercourse?

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* 20. Do you consider your desire for sex normal?

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* 21. Are you able to ejaculate?

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* 22. By what method:

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* 23. Does the semen:

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* 24. Do you have premature ejaculation?

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* 25. Have you noticed any change in the sensation of your penis?

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* 26. Select One

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* 27. Has your problem with sexual dysfunction affected your relationship with your partner?

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* 28. In the past have you received treatment for erectile dysfunction and/or premature ejaculation?

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* 29. If yes. please select treatment type

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* 30. In the past have you received treatment for erectile dysfunction and/or premature ejaculation?

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* 31. Do you have any problems with urination?

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