Men’s Sexual Health Questionnaire

Changes in erections, libido, and sexual performance are common—but that does not mean you have to ignore them. Answer these 10 questions to determine whether it may be time to speak with a provider about your sexual health.

This questionnaire takes approximately two minutes and does not provide a medical diagnosis.

First Name *

Last Name *

Email *

Phone *

May we reach out to you via text? *

Bot protection

I agree to the terms of use

Would you like to subscribe to our newsletter? *

Are you an existing patient? *

Yes

During the past three months, how often have you had difficulty getting an erection firm enough for sexual activity? *

Never

Occasionally

About half the time

Most or all of the time

How often have you had difficulty maintaining an erection through sexual activity? *

Never

Occasionally

About half the time

Most or all of the time

Compared with your previous normal, how would you describe the firmness of your erections? *

No noticeable change

Slightly less firm

Significantly less firm

Rarely or never firm enough for sexual activity

Have you noticed a change in morning or spontaneous erections? *

No change

Slightly less frequent

Much less frequent

Rarely or never experience them

Have you noticed a change in your interest in sex or overall libido? *

No change

Slight decrease

Significant decrease

Little or no sexual interest

How long have you been experiencing these changes? *

I am not currently experiencing changes

Less than one month

One to six months

More than six months

How much are these changes affecting your confidence, relationship, or quality of life? *

Not at all

A little

Moderately

Significantly

If you have tried medication or another treatment for erectile concerns, how well is it working? *

I have not needed treatment

It works reliably

Results are inconsistent

It no longer works well or has not worked

Which of the following apply to you: high blood pressure, high cholesterol, diabetes or elevated blood sugar, excess weight, smoking, sleep apnea, or a history of cardiovascular disease? *

None

One

Two

Three or more

How ready are you to speak with a provider about your sexual health? *

I am only gathering information

I may want to learn more

I am open to an evaluation

I am ready to schedule