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Men's Erectile Dysfunction Score
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LETS GET YOUR ERECTILE DYSFUNCTION SCORE
WHAT IS YOUR E.D. SCORE
Health Insurance will not cover Men's E.D. acoustic Wave Care.
Patients will pay out of pocket for Wave Care, by using Health Savings/ FSA,
debt card, Cash and credit card.
*
Indicates required field
Do you have a planed budget for covering the cost for E.D. Care?
*
Yes
No
Name
*
First
Last
Phone Number
*
How do you want to be contacted?
*
Text Message
Call
What is best time to contact you?
*
Morning
Afternoon
Evening
What is your age?
*
26-35
36-50
50-60
60+
LET'S GET YOU A SCORE.... OVER THE LAST YEAR RATE YOUR SYMPOTMS FROM
1-5
WITH THE NEXT FIVE QUESTIONS. THEN DR.GARDNER WILL TEXT YOU YOUR E.D. SCORE.
1. How often were you able to get an erection during sexual activity?
PLEASE SELECT NUMBER THAT BEST RESPRESENTS YOUR ERECTILE SYMPTOM
*
0- no sexual activity
1- Almost never or never
2- A few times (almost half the time)
3-Sometimes (about half time)
4- Most times (more than half the time)
5- Almost always or always
2.
When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
PLEASE SELECT THE NUMBER THAT BEST REPRESENTS YOUR ERECTILE SYMPTOM
*
0- No sexual activity
1- Almost never or never
2- A few times ( Less than half the time)
3- Sometimes ( about half the time)
4- Most times ( More than half the time)
5- Almost always or always
3. When you attempted intercourse how often where you able to penetrate ( enter) your partner?
PLEASE SELECT THE NUMBER THAT BEST REPRESENTS YOUR ERECTILE SYMPTOM
*
0- No sexual activity
1- Almost never or never
2- A few times ( less than half the time)
3- Sometimes ( about half the time)
4- Most times ( Most than half the time)
5- Almost always or always
4. During sexual intercourse
how often
were you able to maintain your erection after you had penetrated ( entered ) your partner?
PLEASE SELECT THE NUMBER THAT BEST REPRESENTS YOUR ERECTILE SYMPTOM
*
0- No sexual intercourse
1- Almost never or never
2- A few times ( Less than half the time)
3- Sometimes ( about half the time)
4- Most of the time ( more than half the time)
5- Almost always or always
5. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
PLEASE SELECT THE NUMBER THAT BEST REPRESENTS YOUR ERECTILE SYMPTOM
*
0- Did not attempt intercourse
1- Extremely Difficult
2- Very difficult
3- Difficult
4- Slightly Difficult
5- Not Difficult
6. How do you rate your confidence that you could get and keep a erection?
PLEASE SELCET THE NUMBER THAT BEST REPRESENTS YOUR ERECTILE SYMPTOM
*
1-VERY LOW
2- LOW
3- MODERATE
4-HIGH
5- VERY HIGH
Submit
Home
Men's E.D. Care
Men's Erectile Dysfunction Score
Learn about E.D. Wave Care
Muscle & Joint Shock Wave
Heel Pain
>
Heel Pain
Diagnosis Your Heel Pain
Knee Pain
>
Diagnosis Your Knee Pain
Knee Pain
Hip Pain
Low Back Pain
>
Diagnosis Your Back Pain
Low Back Pain
Shoulder Pain
>
Diagnosis Your Shoulder Pain
Shoulder Pain
Elbow Pain
>
Diagnosis Your Elbow Pain
Elbow Pain
Wrist Pain
