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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. Email Address

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* 5. Phone Number

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* 6. Do you smoke?

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* 7. If yes, # packs per day

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* 8. How many years?

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* 9. Alcohol Use?

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* 10. Known  Allergies To Medication

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* 11. Name of Current Medications

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* 12. Preferred Pharmacy - Name & Address

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* 13. Are you current taking any of the following

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* 14. Past Medical History (Examples Hypertension/ Diabetes)

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

  VERY LOW LOW MODERATE HIGH VERY HIGH
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* 16. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?

  ALMOST NEVER OR NEVER FEW TIMES (MUCH LESS THAN HALF THE TIME) SOMETIMES (ABOUT HALF THE TIME) MOST TIMES (MUCH MORE THAN HALF THE TIME) ALMOST ALWAYS OR ALWAYS
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* 17. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?

  ALMOST NEVER OR NEVER FEW TIMES (MUCH LESS THAN HALF THE TIME) SOMETIMES (ABOUT HALF THE TIME) MOST TIMES (MUCH MORE THAN HALF THE TIME) ALMOST ALWAYS OR ALWAYS
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* 18. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

  ALMOST NEVER OR NEVER FEW TIMES (MUCH LESS THAN HALF THE TIME) SOMETIMES (ABOUT HALF THE TIME) MOST TIMES (MUCH MORE THAN HALF THE TIME) ALMOST ALWAYS OR ALWAYS
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* 19. When you attempted sexual intercourse, how often was it satisfactory for you?

  ALMOST NEVER OR NEVER FEW TIMES (MUCH LESS THAN HALF THE TIME) SOMETIMES (ABOUT HALF THE TIME) MOST TIMES (MUCH MORE THAN HALF THE TIME) ALMOST ALWAYS OR ALWAYS
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