Erectile Dysfunction







ED Questionnaire

This patient self-assessment questionnaire can help your patients determine if they suffer from ED. Over the past 6 months:


1. How would you rate your confidence in your ability to get and keep an erection?
_ Very Low – if you selected this add 1 to your score
_ Low – if you selected this add 2 to your score
_ Moderate – if you selected this add 3 to your score
_ High – if you selected this add 4 to your score
_ Very High – if you selected this add 5 to your score

2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
_ No sexual activity – if you selected this add 0 to your score
_ Almost never/never– if you selected this add 1 to your score
_ A few times (much less than half the time) – if you selected this add 2 to your score
_ Sometimes (about half the time) – if you selected this add 3 to your score
_ Most times (much more than half the time) – if you selected this add 4 to your score
_ Almost always/always– if you selected this add 5 to your score

3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
_ Did not attempt intercourse– if you selected this add 0 to your score
_ Almost never/never– if you selected this add 1 to your score
_ A few times (much less than half the time) – if you selected this add 2 to your score
_ Sometimes (about half the time) – if you selected this add 3 to your score
_ Most times (much more than half the time) – if you selected this add 4 to your score
_ Almost always/always– if you selected this add 5 to your score

4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
_ Did not attempt intercourse– if you selected this add 0 to your score
_ Extremely difficult– if you selected this add 1 to your score
_ Very difficult– if you selected this add 2 to your score
_ Difficult– if you selected this add 3 to your score
_ Slightly difficult– if you selected this add 4 to your score
_ Not difficult– if you selected this add 5 to your score

5. When you attempted sexual intercourse, how often was it satisfactory for you?
_ Did not attempt intercourse– if you selected this add 0 to your score
_ Almost never/never– if you selected this add 1 to your score
_ A few times (much less than half the time) – if you selected this add 2 to your score
_ Sometimes (about half the time) – if you selected this add 3 to your score
_ Most times (much more than half the time) – if you selected this add 4 to your score
_ Almost always/always– if you selected this add 5 to your score

Now total your score.

My ED Score is _________.

If you scored 0: You may have complete ED.
If you scored 5: You may have moderate ED.
If you scored 16: You may have mild ED.
If you scored 22: Your score suggests you have none of the symptoms associated with erectile difficulties. If, however, you are still concerned you should talk to your doctor.

Perhaps your result simply confirms suspicions you’ve had for some time now. Or maybe this is the first time you have really considered the fact that you may have ED. Either way, you’re now armed with some very important information. Here are some ways to put that information to work

Positive Next Steps

  • Speak with your doctor. This step is crucial. Your doctor is not only a valuable source for reliable information on ED, but also the person who can get you the treatment you need. Of course, talking about ED – even to your doctor – is never easy. But it’s important to remember that you’re not the only one affected by ED. Your doctor probably gets the same questions you have from other patients every day.
  • Speak to your partner. If you’ve been living with ED for some time now, it’s more than likely your partner has noticed the changes you’ve been coping with. This is the perfect time to open the lines of communication. It only makes sense to let your partner know what you now know – that you may have ED, a condition shared by millions of Canadian men and that there is treatment available.

 

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  Version 2.0, July 2004
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