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International Index of Erectile Function Questionnaire
SUMMARY: Questionnaire for assessing impotence/erectile dysfunction.
Questions: Based on last 6 months (each answer assigned 1-5 score)
1. How do you rate your confidence that you could get and keep an Erection?
A. Very Low - 1 point
B. Low - 2 points
C. Moderate - 3 points
D. High - 4 points
E. Very High - 5 points
Choice --> [select name="Q1" value="A=1|B=2|C=3|D=4|E=5"]

2. When you had Erections with sexual stimulation, how often were your Erections hard enough for penetration?
A. Never or almost never - 1 point
B. A few times - 2 points
C. Sometimes (about half the time) - 3 points
D. Most times - 4 points
E. Always or almost always - 5 points
Choice --> [select name="Q2" value="A=1|B=2|C=3|D=4|E=5"]

During sexual intercourse, how often were you able to maintain your Erection after you had penetrated or entered your partner?
A. Never or almost never - 1 point
B. A few times - 2 points
C. Sometimes (about half the time) - 3 points
D. Most times - 4 points
E. Always or almost always - 5 points
Choice --> [select name="Q3" value="A=1|B=2|C=3|D=4|E=5"]

During sexual intercourse, how difficult was it maintain your Erection to completion of intercourse?
A. Extremely difficult - 1 point
B. Very difficult - 2 points
C. Difficult - 3 points
D. Slightly difficult - 4 points
E. Not difficult - 5 points
Choice --> [select name="Q4" value="A=1|B=2|C=3|D=4|E=5"]

When you attempted sexual intercourse, how often was it satisfactory for you?
A. Never or almost never - 1 point
B. A few times - 2 points
C. Sometimes (about half the time) - 3 points
D. Most times - 4 points
E. Always or almost always - 5 points
Choice --> [select name="Q5" value="A=1|B=2|C=3|D=4|E=5"]

Score --> [calc value="score=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)" memo="total"] points
Interpretation --> [calc value="score2=(Q1)+(Q2)+(Q3)+(Q4)+(Q5);score2>21?'Normal erectile function':score2>16?'Mild erectile dysfunction':score2>11?'Mild to moderate erectile dysfunction':score2>7?'Moderate erectile dysfunction':'Severe erectile dysfunction'" memo="Interpretation"]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference:
[link url="//www.ncbi.nlm.nih.gov/pubmed/10637462" memo="#1"] Rosen (1999) Int J Impot Res. 11:319-26
[link url="//www.fpnotebook.com/Uro/Exam/IntrntnlIndxOfErctlFnctnQstnr.htm" memo="#2"] FPNotebook page
[/conditional]
International Index of Erectile Function Questionnaire
SUMMARY: Questionnaire for assessing impotence/erectile dysfunction.
Questions: Based on last 6 months (each answer assigned 1-5 score)
1. How do you rate your confidence that you could get and keep an Erection?
A. Very Low - 1 point
B. Low - 2 points
C. Moderate - 3 points
D. High - 4 points
E. Very High - 5 points
Choice -->

2. When you had Erections with sexual stimulation, how often were your Erections hard enough for penetration?
A. Never or almost never - 1 point
B. A few times - 2 points
C. Sometimes (about half the time) - 3 points
D. Most times - 4 points
E. Always or almost always - 5 points
Choice -->

During sexual intercourse, how often were you able to maintain your Erection after you had penetrated or entered your partner?
A. Never or almost never - 1 point
B. A few times - 2 points
C. Sometimes (about half the time) - 3 points
D. Most times - 4 points
E. Always or almost always - 5 points
Choice -->

During sexual intercourse, how difficult was it maintain your Erection to completion of intercourse?
A. Extremely difficult - 1 point
B. Very difficult - 2 points
C. Difficult - 3 points
D. Slightly difficult - 4 points
E. Not difficult - 5 points
Choice -->

When you attempted sexual intercourse, how often was it satisfactory for you?
A. Never or almost never - 1 point
B. A few times - 2 points
C. Sometimes (about half the time) - 3 points
D. Most times - 4 points
E. Always or almost always - 5 points
Choice -->

Score --> totalscore=(Q1)+(Q2)+(Q3)+(Q4)+(Q5) points
Interpretation --> Interpretationscore2=(Q1)+(Q2)+(Q3)+(Q4)+(Q5);score2>21?'Normal erectile function':score2>16?'Mild erectile dysfunction':score2>11?'Mild to moderate erectile dysfunction':score2>7?'Moderate erectile dysfunction':'Severe erectile dysfunction'
display/hide references

Result - Copy and paste this output: