📋 IIEF Pre-consultation Questionnaire: Erectile Dysfunction

Erectile dysfunction: IIEF-5 score (International Index of Erectile Function)

Why complete this questionnaire?
The IIEF-5 score is the internationally validated questionnaire used to assess the severity of erectile dysfunction. It will be passed directly to Pr Dohan, Cochin IR to prepare your consultation.

👤 Personal information

Full name *

Date of birth

Email (copy)

Referring physician (urologist, andrologist…)

Planned consultation date

Treatments already tried

PDE5 inhibitors (Viagra/Cialis) Intracavernosal injections None

Result of pharmacological penile Doppler ultrasound (if performed)

📊 IIEF-5 score

For each question, tick the answer that best matches your situation over the past 4 weeks.

Question	Almost never / never (1)	Rarely (less than half the time) (2)	Sometimes (about half the time) (3)	Most of the time (more than half the time) (4)	Almost always / always (5)

💬 Additional information

Description of your symptoms and how they have changed over time

Current treatments

📄 This questionnaire is meant to be completed at home, ahead of your consultation. Fill it in, then print it or save it as a PDF and bring it with you on the day of your appointment. Nothing is sent automatically. If you would like to send it in advance, you can email it yourself via Contact us (at your own responsibility).

For Pr Dohan · IR Cochin