MAMBA # 5 ED Index Score Question Performance Assessment This quick 60-second assessment helps determine whether you may benefit from a clinical evaluation. Your responses are confidential. * Indicates required question Over the past 3 months, how often have you had difficulty achieving or maintaining an erection sufficient for intimacy? Never Occasionally Sometimes Often Almost Always Compared to previous years, how would you describe your erection firmness? Same as before Slightly weaker Noticeably weaker Significantly weaker How confident do you feel about your performance during intimacy? 1 2 3 4 5 1 = Very confident and 5=Not confident at all Has this impacted your self-confidence or overall well-being? Not at all A little Moderately A great deal Have these concerns caused you to avoid intimacy? Never Sometimes Frequently Almost always How often do you wake with morning erections? Almost daily A few times per week Occasionally Rarely or never How often do you avoid intimacy due to erection concerns? Never Occasionally Frequently (I feel embarrassed) Almost always (Due to performance anxiety) How would you rate your sexual stamina? Excellent Good Fair Poor Are you able to maintain an erection during sexual intercourse (direct penetration)? Never Half the time More than half the time Always During intercourse, how difficult di it find to maintain your erection to completion? Extremely difficult Difficult Slightly difficult Not difficult How would you describe the duration of your erections? Long enough for completion Usually adequate Often too short Rarely adequate How satisfied do you think your partner is with your performance? Very satisfied Somewhat satisfied Somewhat dissatisfied Very dissatisfied Name Email Phone Number City Province Send
