Smart MSFI (Priapus Shot®/P-Shot®)

Last Name *

First Name *

Date of Service * +

Email Address: *

Phone Number *

Sex *

Male

Female

Date of Birth * +

Age? *

Which treatment interests you? * 🛈

P-Shot	P-Shot + ESWT
P-Shot + SCR	P-Shot + ESWT + SCR

INSTRUCTIONS: These questions ask about your sexual feelings and responses during the past 4 weeks. Please answer the following questions as honestly and clearly as possible. Your responses will be completely confidential. In answering these questions, the following definitions apply:

Sexual activity can include caressing, foreplay, masturbation and vaginal intercourse.

Sexual intercourse is defined as penile penetration (entry) of the vagina.

Sexual stimulation includes situations like foreplay with a partner, self-stimulation (masturbation) or sexual fantasy.

Sexual desire or interest is a feeling that includes wanting to have a sexual experience, feeling receptive to a partner's sexual initiation, and thinking or fantasizing about having sex.

CHECK ONLY ONE BOX PER QUESTION.

Erection is a physiological phenomenon in which the penis becomes firmer, engorged and enlarged.

1. In the past 4 weeks, without using drugs like Viagra, how often have you been able to get an erection when you wanted to? *

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

2. In the past 4 weeks, if you are able to get an erection, without using drugs like Viagra, how often are you able to stay hard a long as you want to? *

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

3. In the past 4 weeks, if you are able to get an erection, without using drugs like Viagra, how would you rate the hardness of your erections? *

Ejaculation is the discharge of semen (normally containing sperm) from the male reproductory tract, usually accompanied by orgasm.

4. Are you able to ejaculate when having sexual activity with your wife or main partner? *

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

5. In the past 4 weeks, when having sexual activity with your wife or main partner, how often did you feel that you took too long to ejaculate or come "cum"? *

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

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