Patient Profile Survey for Impotence This is a general survey about you, your success in finding relief from Impotence and what effect Impotence has had on your life. About you 1. Your Gender Male
Female
2. Country of Birth. Where were you born Choose one..
United States of America
United Kingdom
Canada
Australia
Germany
Afghanistan
Aland
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Ascension Island
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Virgin Islands
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cap Verde
Cayman Islands
Central African Republic
Chad
Channel Islands
Chile
China
Christmas Island
Cocos (Keeling) Island
Colombia
Comoros
Congo, Republic of
Congo, Democratic Republic of
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Falkland Islands (Malvinas)
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niue
Niger
Nigeria
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudia Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovak Republic
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Virgin Islands
Uruguay
US Minor Outlying Islands
USSR
Uzbekistan
Vanuatu
Vatican City State (Holy See)
Venezuela
Vietnam
Wallis and Futuna Islands
Western Sahara
Yemen
Yugoslavia
Zambia
Zimbabwe
3. Age. What is your current age? Choose one..
0-5 Years
6-12 Years
13-20 Years
21-30 Years
31-40 Years
41-50 Years
51-60 Years
61-70 Years
71-80 Years
Over 80 Years
4. Occupation Type. What is the closest match to your usual occupation Choose one..
School or Retired
Home Duties
Laborer
Tradesman
Clerical or Sales
Professional or Technical
5. Your Income. What is your approximate income before tax? Income P.A. (US$) Choose one..
Unemployed
$1 - $9999
$10,000 - $29,999
$30,000 - $79,999
$80,000 - $149,999
Above $150,000
6. Your Education. Highest level achieved Choose one..
No Education
Primary/Grade School
High School
College/Uni
7. Exercise. How often do you take planned exercise?
Never
Once a month
Once a week
Once a day
About your Impotence 8. Family History. Do you have a family history of Impotence?
Yes
No
Don't Know
9. First Noticed. At what age did you first show symptoms of Impotence? Choose one..
0-5 Years
6-12 Years
13-20 Years
21-30 Years
31-40 Years
41-50 Years
51-60 Years
61-70 Years
71-80 Years
Over 80 Years
Don't Know
10. First Diagnosed. How long after you noticed symptoms of Impotence were you officially diagnosed? Choose one..
Same Day
Same Week
Same Month
3 months
6 months
1 year
2 years
5 years
More than 5 years
Never
Don't Know
11. Time until treatment. How long after you were diagnosed with Impotence were did you have an effective treatment or cure? Choose one..
Same Day
Same Week
Same Month
3 months
6 months
1 year
2 years
5 years
More than 5 years
Never
Don't Know
12. Effect on your life before treatment. What was the effect of Impotence on your life before treatment? Effect
1 - No Effect
2
3
4
5
6
7
8
9
10 - Major Effect
13. Effect on your life after treatment. If you had an effective treatment, what was the effect of Impotence on your life after treatment? Effect
1 - No Effect
2
3
4
5
6
7
8
9
10 - Major Effect
14. Monetary Costs ($US). How much have you spent out of pocket (not coverered by insurance) to obtain medical care and relief from Impotence? Cost
Nothing
Under $50
$51-500
$501-$1000
$1001-$5000
$5001-$10000
$10001-$20000
More than $20000
Don't Know
15. Satisfaction. Are you happy with your experiences of medical care for Impotence? Are you satisfied?
Yes
No
Don't Know/No Care
16. Misdiagnosis. Were you wrongly diagnosed as a result of having Impotence? Were you misdiagnosed?
Yes
No
Don't Know
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