Oswestry Pain Questionnaire - Good Medicine



IIEF-5

name: ______________________________ date: _______

The following 5 questions assess your ability and confidence in being able to get and maintain erections. To the right of each question, please tick the box that describes your experience over the last six months, or other time period that you and your therapist want to evaluate.

| | | | | | |

| |1 |2 |3 |4 |5 |

|how do you rate your confidence that you could get and keep|very low |low |moderate |high |very high |

|an erection? | | | | | |

|when you had erections with sexual stimulation, how often |almost never or |much less than |about half the |much more than |almost always or |

|were your erections hard enough for penetration? |never |half the time |time |half the time |always |

|during sexual intercourse, how often were you able to |almost never or |much less than |about half the |much more than |almost always or |

|maintain your erection after you had penetrated (entered) |never |half the time |time |half the time |always |

|your partner? | | | | | |

|during sexual intercourse how difficult was it to maintain |extremely difficult|very difficult |difficult |slightly difficult|not difficult |

|your erection to the completion of intercourse? | | | | | |

|when you attempted sexual intercourse, how often was it |almost never or |much less than |about half the |much more than |almost always or |

|satisfactory for you? |never |half the time |time |half the time |always |

The numbers at the top of each column give the score for ticking a box in that column.

Your total score is simply the sum of these five numbers. total=

Rosen, R.C., et al., Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. International Journal of Impotence Research, 1999. 11(6): p. 319-26.

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