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How certain do you feel that you can achieve and sustain an erection?
Very high
High
Moderate
Low
Very low
How often do you experience difficulty getting or maintaining an erection?
Always
More than half the time
Sometimes
Rarely
Never
How did your ED start?
Suddenly
Gradually worsened over time
Do you have low sex drive, an overall lack of energy, or a decrease in physical strength or endurance?
Yes
No
Rate the typical hardness of your erection during masturbation.
Penis does not enlarge
Penis is larger, but not hard
Penis is hard, but not hard enough for penetration
Penis is hard enough for penetration, but not completely hard.
Penis is completely hard and fully rigid
Rate the typical hardness of your spontaneous erections in the middle of the night or the morning.
Penis does not enlarge
Penis is larger, but not hard
Penis is hard, but not hard enough for penetration
Penis is hard enough for penetration, but not completely hard.
Penis is completely hard and fully rigid
Rate the typical hardness of your erection with a sexual partner.
Penis does not enlarge
Penis is larger, but not hard
Penis is hard, but not hard enough for penetration
Penis is hard enough for penetration, but not completely hard.
Penis is completely hard and fully rigid
Are you able to maintain erection until orgasm?
Almost always
Most of the time
Sometimes
Only a few times
Almost never
Do you easily get stressed?
All the time
Often
Sometimes
Never
How many hours do you typically sleep per night?
Less than 6 hours
6-7 hours
7-9 hours
More than 9 hours
“Most of the time I feel”
Choose as many or few options as you like
Happy
Sad
Depressed
Anxious
Motivated
Lonely
Indifferent
Other
Do you eat foods rich in vitamin B6 (such as poultry, fish, bananas, or whole grains)?
Yes, regularly
Sometimes
Rarely or never
Do you eat foods rich in vitamin D (such as fatty fish, fortified dairy products, or mushrooms)?
Yes, regularly
Sometimes
Rarely or never
Do you eat foods rich in vitamin K2 (such as fermented foods, cheese, or egg yolks)?
Yes, regularly
Sometimes
Rarely or never
Do you eat foods rich in magnesium and boron (such as nuts, seeds, leafy greens, or legumes)?
Yes, regularly
Sometimes
Rarely or never
Do you eat foods rich in zinc (such as beef, pork, poultry, shellfish, nuts, or seeds)?
Yes, regularly
Sometimes
Rarely or never
Do you currently or have you ever regularly smoked cigarettes?
Yes, I smoke cigarettes on some or most days
Yes, I previously smoked cigarettes but quit
No, I have never regularly smoked cigarettes
Have you smoked, ingested or used any of the following within the past 3 months?
Poppers or Rush (Amyl Nitrate or Butyl Nitrate)
Cannabis
Cocaine
Methamphetamine (crystal meth)
No, I have not used any recreational drugs in the past 3 months
Other
Do you experience any of the following cardiovascular symptoms?
Chest pain when climbing 2 flights of stairs or walking 4 blocks
Chest pain with sexual activity
Severe lightheadedness
None of these apply to me
Do you have or have you previously been diagnosed with any of the following heart conditions?
Abnormal heart beats or rhythms
Idiopathic Hypertrophic Subaortic Stenosis (aka. hypertrophic obstructive cardiomyopathy)
Congestive heart failure
Long QT Syndrome (QT Prolongation)
Coronary artery disease (without prior heart attack)
Other electrical heart abnormalities
Coronary bypass surgery
Coronary angioplasty/stent
Heart attack
None of these apply to me
Did you have your testosterone levels tested?
Yes
No
How tall are you?
We’ll use this to calculate your BMI (Body Mass Index).
Imperial
Metric
How much do you weigh?
We’ll use this to calculate your BMI (Body Mass Index).
lb
kg
How old are you?
We’ll use this to calculate your BMI (Body Mass Index) and current testosterone level.
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