Questionnaire – Partners of Sugar – Take your Diabetes Hypertension & Cardiometabolic Practice Beyond Clinic

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The International Index of Erectile Function Questionnaire (IIEF)

Please complete and bring this questionnaire to your appointment (circle your answers).

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Erectile Function 0%
Intercourse Satisfaction 0%
Orgasmic Function 0%
Overall Satisfaction 0%
Sexual Desire 0%

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Question 1 of 15

1. Question
Over the last month, how often were you able to get an erection during sexual activity?
- No sexual activity
- Almost always or always
- Most times (much more than half the time)
- Sometimes (about half the time)
- A few times (much less than half the time)
- Almost never or never
Correct

Incorrect
Question 2 of 15

2. Question
Over the last month, how many times have you attempted sexual intercourse?
- No attempts
- 1-2 times
- 3-4 times
- 5-6 times
- 7-10 times
- 11-20 times
Correct 5 / 5Points

Incorrect / 5 Points
Question 3 of 15

3. Question
Over the last month, when you attempted intercourse, how often were you able to penetrate your partner?
- No sexual activity
- Almost always or always
- Most times (much more than half the time)
- Sometimes (about half the time)
- A few times (much less than half the time)
- Almost never or never
Correct 5 / 5Points

Incorrect / 5 Points
Question 4 of 15

4. Question
Over the last month, during sexual intercourse, how often were you able to
maintain your erection after you had pentrated your partner?
- No sexual activity
- Almost always or always
- Most times (much more than half the time)
- Sometimes (about half the time)
- A few times (much less than half the time)
- Almost never or never
Correct 5 / 5Points

Incorrect / 5 Points
Question 5 of 15

5. Question
Over the last month, during sexual intercourse, how difficult was it to maintain
your erection to completion of intercourse?
- No sexual activity
- Extremely difficult
- Very difficult
- Difficult
- Slightly difficult
- Not difficult
Correct 5 / 5Points

Incorrect / 5 Points
Question 6 of 15

6. Question
Over the last month, how many times have you attempted sexual intercourse?
- No attempts
- 1-2 times
- 3-4 times
- 5-6 times
- 7-10 times
- 11-20 times
Correct 5 / 5Points

Incorrect / 5 Points
Question 7 of 15

7. Question
Over the last month, when you attempted sexual intercourse how often was it satisfactory for you?
- Did not attempt intercourse
- Almost always or always
- Most times (much more than half the time)
- Sometimes (about half the time)
- A few times (much less than half the time)
- Almost never or never
Correct 5 / 5Points

Incorrect / 5 Points
Question 8 of 15

8. Question
Over the last month, how much have you enjoyed sexual intercourse?
- No intercourse
- Very highly enjoyable
- Highly enjoyable
- Fairly enjoyable
- Not very enjoyable
- No enjoyment
Correct 5 / 5Points

Incorrect / 5 Points
Question 9 of 15

9. Question
Over the last month, when you had sexual stimulation or intercourse, how often did you ejaculate?
- No sexual stimulation/intercourse
- Almost always or always
- Most times (much more than half the time)
- Sometimes (about half the time)
- A few times (much less than half the time)
- Almost never or never
Correct 5 / 5Points

Incorrect / 5 Points
Question 10 of 15

10. Question
Over the last month, when you had sexual stimulation or intercourse, how often did you have the feeling of orgasm (with or without ejaculation)?
- No sexual stimulation/intercourse
- Almost always or always
- Most times (much more than half the time)
- Sometimes (about half the time)
- A few times (much less than half the time)
- Almost never or never
Correct 5 / 5Points

Incorrect / 5 Points
Question 11 of 15

11. Question
Over the last month, how often have you felt sexual desire?
- Almost always or always
- Most times (much more than half the time)
- Sometimes (about half the time)
- A few times (much less than half the time)
- Almost never or never
Correct 5 / 5Points

Incorrect / 5 Points
Question 12 of 15

12. Question
Over the last month, how would you rate your level of sexual desire?
- Very high
- High
- Moderate
- Low
- Very low or not at all
Correct 5 / 5Points

Incorrect / 5 Points
Question 13 of 15

13. Question
Over the last month, how satisfied have you been with your overall sex life?
- Very satisfied
- Moderately satisfied
- About equally satisfied and dissatisfied
- Moderately dissatisfied
- Very dissatisfied
Correct 5 / 5Points

Incorrect / 5 Points
Question 14 of 15

14. Question
Over the last month, how satisfied have you been with your sexual relationship with your partner?
- Very satisfied
- Moderately satisfied
- About equally satisfied and dissatisfied
- Moderately dissatisfied
- Very dissatisfied
Correct 5 / 5Points

Incorrect / 5 Points
Question 15 of 15

15. Question
Over the last month, how do you rate your confidence that you can get and keep your erection?
- Very high
- High
- Moderate
- Low
- Very low
Correct 5 / 5Points

Incorrect / 5 Points

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Sleep Quality Assessment (PSQI)

What is PSQI, and what is it measuring?
The Pittsburgh Sleep Quality Index (PSQI) is an effective instrument used to measure the quality and patterns of sleep in adults. It differentiates “poor” from “good” sleep quality by measuring seven areas (components): subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction over the last month.

INSTRUCTIONS:
The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most
accurate reply for the majority of days and nights in the past month. Please answer all questions.

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Question 1 of 19

1. Question
When have you usually gone to bed?
- (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12)
Correct 1 / 1Points

Incorrect / 1 Points
Question 2 of 19

2. Question
How long (in minutes) has it taken you to fall asleep each night?
- <15min
- 16-30min
- 31-60 min
- >60min
Correct 3 / 3Points

Incorrect / 3 Points
Question 3 of 19

3. Question
What time have you usually gotten up in the morning?
- (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12)
Correct

Incorrect
Question 4 of 19

4. Question
A. How many hours of actual sleep did you get at night?
Correct 2 / 2Points

Incorrect / 2 Points
Question 5 of 19

5. Question
B. How many hours were you in bed?
Correct 2 / 2Points

Incorrect / 2 Points
Question 6 of 19

6. Question
A. Cannot get to sleep within 30 minutes
- Not during the past month
- Less than once a week
- Once or twice a week
- Three or more times a week
Correct 3 / 3Points

Incorrect / 3 Points
Question 7 of 19

7. Question
B. Wake up in the middle of the night or early morning
- Not during the past month
- Less than once a week
- Once or twice a week
- Three or more times a week
Correct 3 / 3Points

Incorrect / 3 Points
Question 8 of 19

8. Question
C. Have to get up to use the bathroom
- Not during the past month
- Less than once a week
- Once or twice a week
- Three or more times a week
Correct 3 / 3Points

Incorrect / 3 Points
Question 9 of 19

9. Question
D. Cannot breathe comfortably
- Not during the past month
- Less than once a week
- Once or twice a week
- Three or more times a week
Correct 3 / 3Points

Incorrect / 3 Points
Question 10 of 19

10. Question
E. Cough or snore loudly
- Not during the past month
- Less than once a week
- Once or twice a week
- Three or more times a week
Correct 3 / 3Points

Incorrect / 3 Points
Question 11 of 19

11. Question
F. Feel too cold
- Not during the past month
- Less than once a week
- Once or twice a week
- Three or more times a week
Correct 3 / 3Points

Incorrect / 3 Points
Question 12 of 19

12. Question
G. Feel too hot
- Not during the past month
- Less than once a week
- Once or twice a week
- Three or more times a week
Correct 3 / 3Points

Incorrect / 3 Points
Question 13 of 19

13. Question
H. Have bad dreams
- Not during the past month
- Less than once a week
- Once or twice a week
- Three or more times a week
Correct 3 / 3Points

Incorrect / 3 Points
Question 14 of 19

14. Question
I. Have pain
- Not during the past month
- Less than once a week
- Once or twice a week
- Three or more times a week
Correct 3 / 3Points

Incorrect / 3 Points
Question 15 of 19

15. Question
J. Other reason (s), please describe, including how often you have had trouble sleeping because of this reason (s):
- Not during the past month
- Less than once a week
- Once or twice a week
- Three or more times a week
Correct 3 / 3Points

Incorrect / 3 Points
Question 16 of 19

16. Question
During the past month, how often have you taken medicine (prescribed or “over the counter”) to help you sleep?
- Not during the past month
- Less than once a week
- Once or twice a week
- Three or more times a week
Correct 3 / 3Points

Incorrect / 3 Points
Question 17 of 19

17. Question
During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in
social activity?
- Not during the past month
- Less than once a week
- Once or twice a week
- Three or more times a week
Correct 3 / 3Points

Incorrect / 3 Points
Question 18 of 19

18. Question
During the past month, how much of a problem has it been for you to keep up enthusiasm to get things done?
- Not during the past month
- Less than once a week
- Once or twice a week
- Three or more times a week
Correct 3 / 3Points

Incorrect / 3 Points
Question 19 of 19

19. Question
During the past month, how would you rate your sleep quality overall?
- Very good
- Fairly good
- Fairly bad
- Very bad (3)
Correct 3 / 3Points

Incorrect / 3 Points

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Quiz-summary

Information

The International Index of Erectile Function Questionnaire (IIEF)

Results

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1. Question

2. Question

3. Question

4. Question

5. Question

6. Question

7. Question

8. Question

9. Question

10. Question

11. Question

12. Question

13. Question

14. Question

15. Question

Quiz-summary

Information

Sleep Quality Assessment (PSQI)

Results

Categories

1. Question

2. Question

3. Question

4. Question

5. Question

6. Question

7. Question

8. Question

9. Question

10. Question

11. Question

12. Question

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