ES Jeffrey Epstein HEF NAME DATE OF BIRTHAN. 20, 1953 9 East 71st Street ADDRESS — NY, NY 10021 TELEPHONE 212-750.9895 Chairman Dept. of Urology icann Schoo! of Medicine at Mount Sinai Ph: (212) 241-9955 AGE6 3 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 . a 2 Afew times (less than half of the time) 0 ai How often were you able to get an erection during sexual “ gohoan batet tha te activity? 4. Most times (more than half of the time) always or always © No sexual activity 1 Almost never or never ‘ . . 2 Afew times (less than half of the time) 0 a2 When you had erections with sexual stimulation, how often = edicas tifa the Ge were your erections hard enough for penetration? Most times (more than half of the time) always or always O Did not attempt intercourse 1 Almost never or never 2 A few times (less than half of the time) 0 a3 When you attempted intercourse, how often were you able to . Seiretthe ee penetrate (enter) your partner? Most times (more than half of the time) Almost always or always 0 Did not attempt intercourse 1 Almost never or never 2 A few times (less than half of the time) fe) a4 During sexual intercourse, how often were you able to maintain 4 secs Gaba hakret tha tice your erection after you had penetrated (entered) your partner? © Most times (more than half of the time) 5S Almost always or always EFTA00314084