International Index of Erectile Dysfunction 15

International Index of Erectile Dysfunction

(IIEF) Questionnaire (Merit Medical)
PATIENT NAME:
DOB:
TODAY'S DATE:

MonthDayYear
Date
The first five questions refer to erectile function.
1. Over the last month, how often were you able to get an erection during sexual activity?

No Sexual ActivityAlmost always or alwaysMost times (much more than half the time)Sometimes (about half the time)A few times (much less than half the time)Almost never or never
2. Over the last month, when you had erections with sexual stimulations, how often were your erections hard enough for penetration?

No Sexual ActivityAlmost always or alwaysMost times (much more than half the time)Sometimes (about half the time)A few times (much less than half the time)Almost never or never
3. Over the last month, when you attempted intercourse, how often were you able to penetrate your partner?

No Sexual ActivityAlmost always or alwaysMost times (much more than half the time)Sometimes (about half the time)A few times (much less than half the time)Almost never or never
4. Over the last month, during sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?

No Sexual ActivityAlmost always or alwaysMost times (much more than half the time)Sometimes (about half the time)A few times (much less than half the time)Almost never or never
5. Over the last month, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

No Sexual ActivityExtremely difficultVery difficultDifficultSlightly difficultNot difficult
The next three questions refer to satisfaction with intercourse.
6. Over the last month, how many times have you attempted sexual intercourse?

No attempts1-2 times3-4 times5-6 times7-10 times11-20 times
7. Over the last month, when you attempted sexual intercourse how often was it satisfactory for you?

No sexual activityAlmost always or alwaysMost times (much more than half the time)Sometimes (about half the time)A few times (much less than half the time)Almost never or never
8. Over the last month, how much have you enjoyed sexual intercourse?

No intercourseVery highly enjoyableHighly enjoyableFairly enjoyableNot very enjoyableNo enjoyment
The next two questions refer to orgasmic function.
9. Over the last month, when you had sexual stimulation or intercourse, how often did you ejaculate?

No sexual stimulation/intercourseAlmost always or alwaysMost times (much more than half the time)Sometimes (about half the time)A few times (much less than half the time)Almost never or never
10. Over the last month, when you had sexual stimulation or intercourse, how often did you have the feeling of orgasm (with or without ejaculation)?

No sexual stimulation/intercourseAlmost always or alwaysMost times (much more than half the time)Sometimes (about half the time)A few times (much less than half the time)Almost never or never
The next two questions ask about sexual desire. In this context, sexual desire is defined as a feeling that may include wanting to have a sexual experience (for example, masturbation or sexual intercourse), thinking about having sex, or feeling frustrated due to lack of sex.
11. Over the last month, how often have you felt sexual desire?

Almost always or alwaysMost times (much more than half the time)Sometimes (about half the time)A few times (much less than half the time)Almost never or never
12. Over the last month, how would you rate your level of sexual desire?

Very highHighModerateLowVery low or not at all
The next two questions refer to overall sexual satisfaction.
13. Over the last month, how satisfied have you been with your overall sex life?

Very satisfiedModerately satisfiedAbout equally satisfied and dissatisfiedModerately dissatsfiedVery dissatisfied
14. Over the last month, how satisfied have you been with your sexual relationship with your partner?

Very satisfiedModerately satisfiedAbout equally satisfied and dissatisfiedModerately dissatsfiedVery dissatisfied
The last questions refers to erectile function.
15. Over the last month, how do you rate your confidence that you can get and keep your erection?

Very highHighModerateLowVery low
ADD YOUR SCORES

Area	Questions	Score Range	Maximum Score	Your Score
Erectile Function	1-5 & 15	0-5	30
Orgasmic Function	9-10	0-5	10
Sexual Desire	11-12	1-5	10
Intercourse Satisfaction	6-8	0-5	15
Overall Satisfaction	13-14	1-5	10

SCORING:

1-10: Severe Erectile Dysfunction

11-16: Moderate dysfunction

17-21: Mild to moderate dysfunction

22-25: Mild dysfunction

26-30: No dysfunction

This information, including the questions, structure and completeness of the sample survey, is based on forms and/or scoring systems developed by independent organizations of relevance to the diagnosis and treatment of benign prostatic hyperplasia (BPH This material is not a substitute for a consultation or physical examination by a physician. Merit Medical disclaims any liability for the decisions a patient makes based on this information.
TOTAL
403728001A ID 071717
Should be Empty:

International Index of Erectile Dysfunction

ADD YOUR SCORES