Mount Sinai C-cl rman De of 1.00;', ICr School c• Meacire a: S na. O. (2:2i 2e-9955 Patient Questionnaire IIEF NAME Jeffrey Epstein DATE OF BIRTH-lain 20, 1953 ADDRESS 9 East 71st Street NY, NY 10021 AGE 6 3 TELEPHONE 212.750.9895 These questions ask about the effects that your erection problems have had on your sex life over the last four weeks. Please try to answer the questions as honestly and as clearly as you are able. Your answers will help your doctor to choose the most effective treatment suited to your condition. In answering the questions, the following definitions apply: • sexual activity includes intercourse, caressing, foreplay, & masturbation. • sexual intercourse is defined as sexual penetration of your partner. • sexual stimulation includes situation such as foreplay, erotic pictures, etc. • ejaculation is the ejection of semen from the penis (or the feeling of this). • orgasm is the fulfillment or climax following sexual stimulation or intercourse. Over the past 4 weeks: 0 No sexual activity 1 Almost never or never 0 Q1 How often were you able to get an erection during sexual activity? 2 A few times (less than half of the time) 3 Sometime (about half of the time) 4 Most times (more than half of the time) C asJmou always or always o No sexual activity 1 Almost never or never 0 Q2 When you had erections with sexual stimulation, how often were your erections hard enough for penetration? 2 A few times (less than half of the tune) 3 Sometime (about half of the time) 4 Most times (more than half of the time) gjAlmost always or always 0 DA not attempt intercourse 1 Almost never or never 0 Q3 When you attempted intercourse, how often were you able to penetrate (enter) your partner? 2 A few times [less than half of the time) 3 Sometime (about half of the time) 4,4 Most times (more than halt of the time) PAknost always or always 0 Did not attempt intercourse 1 Almost never or never 0 Q4 During se