IN THE LAST THREE MONTHS

have you used any drugs, such as:

Prescription (peptic ulcer drugs, antidepressants, blood pressure medications, sedatives, or hormones)?
Over-the-counter (cold or allergy medications, aspirin, antacids, vitamins, or herbal preparations)?
Recreational (marijuana, cocaine, or amphetamine)?
Tobacco (cigarettes, cigars, or chewing tobacco)?
Alcohol?
Do you have erection problems?
Did your erection problem begin suddenly?
Do you get erections but have problems keeping them?
Do you ever wake up in the morning with an erection?
Is your erection rigid enough for intercourse?
Can you get an erection by fantasizing or masturbating?
Do you have any problems climaxing or ejaculating?
Are you and your partner sexually attracted to each other?
Are you emotionally attracted to each other?
Are there any ways you feel rejected by each other?
Are you and your partner having problems with your relationship?
Are you arguing with your partner a lot these days?
Do you talk things over with your partner?
Will your partner take part in treatment with you?

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