Please enable JavaScript in your browser to complete this form. OVER THE PAST 4 WEEKS CHECK ONE BOX ONLYName *Mobile Number *Email *Martial Status & Duration *Sex *Age *Describe your experience in words 1 Over the past 6 months, how often were you able to get an erection (hardness in penis) during sexual activity?No sexual activity or tried to avoid any sexual activityAlmost always or always (in most of the cases)Most times (nearly half of the cases)Sometimes (in very few cases or only once or twice) Almost never or never2 Over the past 6 months, when you had erections with sexual stimulation, how often were your erections hard enough for penetration (insert into female private part)?No sexual stimulation or tried to avoid any sexual activityAlmost always or always (in most of the cases)Most times (nearly half of the cases) Sometimes (in very few cases or only once or twice) Almost never or never3 Over the past 6 months, when you attempted sexual intercourse, how often were you able to penetrate (enter) your sexual partner?Did not attempt intercourse or tried to avoid intercourseAlmost always or always (in most of the cases)Most times (nearly half of the cases)Sometimes (in very few cases or only once or twice) Almost never or never4 Over the past 6 months, during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?Did not attempt intercourse or tried to avoid intercourseAlmost always or always (in most of the cases)Most times (nearly half of the cases) Sometimes (in very few cases or only once or twice) Almost never or never5 Over the past 6 months, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?Did not attempt intercourse or tried to avoid intercourseAlmost always or always (in most of the cases)Most times (nearly half of the cases) Sometimes (in very few cases or only once or twice) Almost never or never6 Over the past 6 months, how many times have you attempted sexual intercourse?No attempts or tried to avoid intercourse1-2 attempts/week3-4 attempts/week5-6 attempts/week7-10 attempts/week11 or more attempts/week7 If you have taken any treatment for your problem, how often you have experienced that the treatment is effective? Did not attempt intercourse even after taking the treatmentAlmost always or always (in most of the cases)Most times (nearly half of the cases)Sometimes (in very few cases or only once or twice) Did not work at all8 If you have taken any treatment for your problem, how often you have experienced that only when you continue the treatment the effect is present and after you discontinue the drug it problem rises again?Almost alwaysAfter sometime of quitting the treatmentNever took the treatment completely 9 Over the past 6 months, during any sexual stimulation or intercourse how often did you ejaculate (release semen)?Did not attempt intercourse or tried to avoid intercourseAlmost always or always (in most of the cases)Most times (nearly half of the cases) Sometimes (in very few cases or only once or twice) Almost never or never10 Over the past 6 months, when you had sexual stimulation or intercourse how often did you have the feeling of orgasm or climax or satisfaction (with or without ejaculation)?No sexual stimulation or intercourse or tried to avoid intercourseAlmost always or always (in most of the cases)Most times (nearly half of the cases) Sometimes (in very few cases or only once or twice) Almost never or neverNameSubmit
