* Required Information

Patient's Information

FOLLOW UP QUESTIONNAIRE

Please answer the following questions to measure your erectile improvement to date:

**If prior use of PDE5i [i.e., Viagra, Cialis] please answer questions below.

The Erectile Hardness Score

Now please fill out the questionnaire you took before treatment #1. Your initial score was:

SHIM (Sexual Health Inventory for Men) SCORE

Please answer the following questions to measure your current situation:

Add the numbers you have chosen in question 1-5

The Sexual Health Inventory for Men classifications for ED severity:

Select a country first.