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Questionnaire for Erectile Dysfunction

Questionnaire for Erectile Dysfunction-Medanta-Stumbit Questionnaire
Credit: www.medanta.org

Here's a more detailed questionnaire specifically tailored for Erectile Dysfunction assessment:

  1. Personal Information:

    • Age:
    • Gender:
    • Ethnicity:
    • Occupation:
  2. Medical History:

    • Do you have any chronic medical conditions? If yes, please specify:
    • Are you currently being treated for any medical conditions? If yes, please specify:
    • Have you had any surgeries or procedures in the past? If yes, please specify:
  3. Lifestyle Factors:

    • Do you smoke cigarettes or use tobacco products?
    • How often do you consume alcohol? Please specify the frequency and quantity:
    • Do you use recreational drugs? If yes, please specify the types and frequency:
  4. Medication History:

    • Are you currently taking any prescription medications? If yes, please specify:
    • Are you taking any over-the-counter medications or supplements? If yes, please specify:
  5. Erectile Function:

    • How would you rate the quality of your erections during sexual activity?
      • Excellent
      • Good
      • Fair
      • Poor
      • Very poor
    • How often do you experience difficulty getting an erection when you want to engage in sexual activity?
      • Never
      • Rarely
      • Sometimes
      • Often
      • Always
    • Can you achieve an erection through self-stimulation (masturbation)?
      • Yes, always
      • Yes, sometimes
      • No, rarely
      • No, never
    • Can you maintain an erection during sexual activity?
      • Yes, always
      • Yes, most of the time
      • Sometimes
      • Rarely
      • Never
    • Do you have morning erections?
      • Yes, regularly
      • Yes, occasionally
      • No, rarely
      • No, never
  6. Psychological Factors:

    • Do you experience stress or anxiety related to sexual performance?
    • Have you experienced any traumatic sexual experiences in the past?
    • Do you have any psychological conditions such as depression or anxiety?
  7. Relationship Factors:

    • Are you currently in a relationship? If yes, how satisfied are you with your sexual relationship?
      • Very satisfied
      • Satisfied
      • Neutral
      • Dissatisfied
      • Very dissatisfied
  8. Additional Symptoms:

    • Have you experienced any pain or discomfort during sexual activity or erections?
    • Do you have any other symptoms related to sexual function that you would like to mention?
  9. Impact on Daily Life:

    • How does erectile dysfunction affect your quality of life and relationships?
  10. Additional Comments:

    • Please feel free to share any additional information or concerns you may have regarding your sexual health.

Once completed, it is advisable to discuss the questionnaire responses with a healthcare professional for further evaluation and appropriate management of erectile dysfunction.

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