General QOL - Quality of Life - Assesment

Answer based on your Sexual and Urinary Function activity over the last 4 weeks ....

Survey Date *
Survey Date
Name *
Date of Birth *
Date of Birth
Q1 - Are you having Erections? *
SHIM Score with Medication
Q7 - Do you have a Penile Implant?
Q10 - Do you use a VACUUM Device?
IPSS or AUA Symptom Score