I. Indications

II. Questions: Based on last 6 months (each answer assigned 1-5 score)

  1. How do you rate your confidence that you could get and keep an Erection?
    1. Score 1: Very Low
    2. Score 2: Low
    3. Score 3: Moderate
    4. Score 4: High
    5. Score 5: Very High
  2. When you had Erections with sexual stimulation, how often were your Erections hard enough for penetration?
    1. Score 1: Never or almost never
    2. Score 2: A few times
    3. Score 3: Sometimes (about half the time)
    4. Score 4: Most times
    5. Score 5: Always or almost always
  3. During sexual intercourse, how often were you able to maintain your Erection after you had penetrated or entered your partner?
    1. Score 1: Never or almost never
    2. Score 2: A few times
    3. Score 3: Sometimes (about half the time)
    4. Score 4: Most times
    5. Score 5: Always or almost always
  4. During sexual intercourse, how difficult was it maintain your Erection to completion of intercourse?
    1. Score 1: Extremely difficult
    2. Score 2: Very difficult
    3. Score 3: Difficult
    4. Score 4: Slightly difficult
    5. Score 5: Not difficult
  5. When you attempted sexual intercourse, how often was it satisfactory for you?
    1. Score 1: Never or almost never
    2. Score 2: A few times
    3. Score 3: Sometimes (about half the time)
    4. Score 4: Most times
    5. Score 5: Always or almost always

III. Interpretation: Based on total sum of scores from 5 questions above

  1. Scores 22 to 25: Normal
  2. Scores 17 to 21: Mild
  3. Scores 12 to 16: Mild to moderate
  4. Scores 8 to 11: Moderate
  5. Scores 5 to 7: Severe

Images: Related links to external sites (from Google)

Calculation (SoapNote.org)