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Impotence Assessment Questionnaire

Questions Your Doctor May Ask - and Why!

During a consultation, your doctor will use various techniques to assess the symptom: Impotence. These will include a physical examination and possibly diagnostic tests. (Note: A physical exam is always done, diagnostic tests may or may not be performed depending on the suspected condition) Your doctor will ask several questions when assessing your condition. It is important to openly share any pertinent information to help your doctor make an accurate diagnosis.

It is also very important to bring an up-to-date list of all of your all medical conditions, medications including dosages, and names of numbers of any specialist you see.

Create your printable checklist by answering questions that your doctor may ask below:

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  1. How long have you had problems with impotence?

    Why: to determine if acute or chronic.

  2. Is the sexual problem truly impotence?

    Why: i.e. inability to achieve or maintain an erection of sufficient quality for satisfactory sexual intercourse. Some people often mistakenly use the term impotence to mean other sexual problems such as premature ejaculation, failure to ejaculate, pain with ejaculation (may suggest urethral stricture or prostate cancer).

  3. Sudden or gradual onset of the difficulties?

    Why: gradual onset often suggests an organic cause (i.e. due to medical problems) while sudden onset often suggests a psychological cause (i.e. depression, bereavement, stress, fatigue, performance anxiety, anger and relationship problems).

  4. How often do you have problems with impotence?

    Why: to determine if intermittent and situational or total (occurs across all situations).

  5. What is the age of the person with the impotence?

    Why: it is normal for older men to notice that it takes longer to achieve an erection, it takes longer to achieve subsequent erections and that the penis is less hard when erect. However, no matter what age you are, if you are physically unable to achieve or maintain an erection sufficient for satisfactory sexual activity you should see your doctor for assessment and treatment.

  6. Do you still have early morning erections or are you able to achieve erections and ejaculation with masturbation?

    Why: if yes, suggests difficulties may be due to psychological cause rather than a medical cause.

  7. Stress levels?

    Why: this is one of the key factors for causing sexual problems. Stress lowers the levels of some male body chemicals and thus may have the effect of reducing sexual desire and reducing the ability to perform when you do try.

  8. Relationship problems?

    Why: problems in a relationship can cause sexual dysfunction. e.g. are you and your partner sexually attracted to each other?, how often do you argue with your partner?, do you talk things over with your partner?, how is your love for your partner?

  9. History of trauma or accidents?

    Why: spinal cord injury, injury to sex organs or broken bones in the pelvic area may cause nerve damage that interrupts the connection between the nervous system and the penis.

  10. Past medical history?

    Why: many sexual problems are associated with other physical conditions e.g. high blood pressure, stroke, heart disease, diabetes, peripheral vascular disease, multiple sclerosis, hormonal disorders ( hyperthyroidism, hypothyroidism, hypogonadism, high prolactin levels), kidney disease, liver disease, prostate enlargement or cancer, Peyronie's disease.

  11. Past surgical history?

    Why: surgery to organs such as prostate, bladder or colon may damage nerves that interrupt the connection between the nervous system and the penis.

  12. Previous radiotherapy to the pelvis?

    Why: may cause sexual dysfunction.

  13. Medications?

    Why: some medications can cause erection problems as a side effect e.g. diuretics (thiazides), some high blood pressure medications (beta-blockers and aldomet), some cholesterol lowering drugs (statins), some diabetes medications, some antidepressants (tricyclics), cancer treatments, some anti-ulcer medications (cimetidine and zantac), tranquilizers (phenothiazines) and epilepsy medications; SSRI antidepressant may cause difficulty with erection and also difficulty with ejaculation if erection is achieved.

  14. Smoking history?

    Why: smoking increases the risk of atherosclerosis and peripheral vascular disease which is a major cause of erectile dysfunction.

  15. Alcohol history?

    Why: alcohol abuse or intoxication may cause sexual dysfunction.

  16. Illegal drug history?

    Why: substance abuse may cause sexual dysfunction e.g. marijuana, cocaine, amphetamines, heroin.

  17. Use of anabolic steroids to build muscle bulk?

    Why: may affect sexual dysfunction.

  18. Family history?

    Why: e.g. high blood pressure, heart disease, stroke, peripheral vascular disease, diabetes.

  19. Symptoms of depression?

    Why: e.g. sadness, crying spells, lack of interest in activities, poor energy, poor concentration and attention span, poor sleep, reduced libido, poor self esteem and sometimes suicidal thoughts - if you are depressed it is common to have problems with erection and ejaculation due to the physical and emotional state of your body when you are depressed. Treating the depression may alleviate the erection problems as well. It is important to remember that sexual dysfunction due to a physical cause can also increase the risk of developing depression.

  20. Symptoms of anxiety?

    Why: e.g. nervousness, shakiness, tremor, restlessness, irritability, insomnia, poor concentration, heart palpitations, racing heart, sweating, dizziness, diarrhea, lump in throat and frequency of urination - anxiety and worry can affect your sexual function.

  21. Symptoms of prostate cancer?

    Why: e.g. pain with urination, weak urine stream, urinary retention (unable to urinate), urinary tract infection, erectile difficulty, pain with ejaculation, symptoms of metastases (weight loss, bone pain, numbness or weakness in legs).

Conditions listing medical symptoms: Impotence:

The following list of conditions have 'Impotence' or similar listed as a symptom in our database. This computer-generated list may be inaccurate or incomplete. Always seek prompt professional medical advice about the cause of any symptom.

Select from the following alphabetical view of conditions which include a symptom of Impotence or choose View All.

View All A B C D E F G H I K L M N O P Q R S T U V W

Conditions listing medical complications: Impotence:

The following list of medical conditions have 'Impotence' or similar listed as a medical complication in our database.


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