Name *

First Name

Last Name

1. How do you rate your confidence that you could keep an erection? *

1 Very low

2 Low

3 Moderate

4 High

5 Very high

2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)? *

1. Almost never or never

2. A few times (much less than half the time)

3. Sometimes (about half the time)

4. Most times (more than half the time)

5. Almost always or always

3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? *

1. Almost never or never

2. A few times (much less than half the time)

3. Sometimes (about half the time)

4. Most times (more than half the time)

5. Almost always or always

4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? *

1. Extremely difficult

2. Very difficult

3. Difficult

4. Slightly difficult

5. Not difficult

5. When you attempted sexual intercourse, how often was it satisfactory for you? *

1. Almost never or never

2. A few times (much less than half the time)

3. Sometimes (about half the time)

4. Most times (more than half the time)

5. Almost always or always

Name *

First Name

Last Name

Quality of Life Question. If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that? *

0. Delighted

1. Pleased

2. Mostly satisfied

3. Mixed

4. Mostly dissatisfied

5. Unhappy

6. Terrible

Would you be interested in learning about a minimally invasive option that could allow you to avoid or discontinue enlarged prostate medications? *

Yes

No