PROFORMA

Name:

Hospital Number: Age (in years) of patient:

Age (in years) of spouse:

Marital status: Single/Married/Separated/Divorced/Widower

Duration of marriage:

Were you married before you developed epilepsy? Yes/No

If yes, was the illness disclosed? Yes/No

Number of sexual partners:

Occupation: Patient:
Spouse:

Religion: Hindu/Christian/Muslim/Others

Number of Children:

Were any children born after you developed epilepsy?

Number of people staying in the same house:

Do you have a separate bedroom? Yes/No

Residence: Urban/Rural

Years of Schooling:

Literacy: Read and write/Read only/Illiterate

Type of house:1) Concrete with more than 2 rooms 2) Concrete with 2 or less rooms
3) Mud thatched house 4) No house

House Ownership: Own/Rented/Squatting

Unable to buy food in the last month: No/Yes

Education of the head of the family: Professional degree/ Graduate or postgraduate/ Intermediate
or post high school diploma/ High school certificate/ Middle school certificate/ Primary school
certificate/ Illiterate
Occupation of the head of the family: Professional/Semi-professional/Clerical, shop-owner/farm/
Skilled worker/Semi-skilled worker/Unskilled worker/Unemployed

Income of the family per month:

Patient income per month:

Are you in debt? No/Yes If yes how much?

Any substance use? No/Yes

Type of epilepsy: Primary/ Secondary; Focal/ Generalized

Total duration of illness:

Age of onset of seizures:

Number of seizures in the last one year:

Number of seizures in the last month:

Last seizure:

Drugs taking/ taken:

S.No. Name Started when Till when Mean daily dose

MRI: Normal/Abnormal Details:

CT: Normal/Abnormal Details:

EEG: Normal/Abnormal Details:

Medical Illness: Yes/No

If yes give details

Biometric measurements:
Height
Weight
BMI
Blood investigations:
S. Testosterone:
S. Drug level:

Sexual Misconception: Yes/No

If yes details:

Marital satisfaction: Yes/No

IIEF scores:
Subscales
Erectile function
Orgasmic function
Sexual desire
Intercourse satisfaction
Overall satisfaction

Chinese Index of Sexual Function for Premature Ejaculation (CIPE-5) score:

Additional questions for DSM-5 Diagnosis

Question I:
Do you experience marked delay or infrequency or absence of ejaculation in at least 75% of
partnered sexual activity without you desiring it? Yes/No

How long has this been a problem?....................... months/years

Is it Lifelong or Acquired
Is it Generalized or Situational

Does it cause significant distress? Yes/No If so: Mild/Moderate/Severe

Question II:
Do you experience marked difficulty in obtaining an erection or maintaining an erection till
completion of sexual activity or marked decrease in penile rigidity in at least 75% of sexual
activity? Yes/No

How long has this been a problem?....................... months/years

Is it Lifelong or Acquired
Is it Generalized or Situational

Does it cause significant distress? Yes/No If so: Mild/Moderate/Severe

Question III:
Do you experience deficiency in sexual/erotic thoughts or fantasies and desire for sexual
activity? Is it persistent or recurrent? Yes/No
How long has this been a problem?....................... months/years
Is it Lifelong or Acquired
Is it Generalized or Situational

Does it cause significant distress? Yes/No If so: Mild/Moderate/Severe

Question IV:
Do you ejaculate within one minute of penetration or before you wish it to happen during most
of (75%) the partnered sexual activity? Is this recurrent or persistent? Yes/No
IVLT: 30 seconds to 1 minute/15-30 seconds/less than 15 seconds
How long has this been a problem?....................... months/years
Is it Lifelong or Acquired
Is it Generalized or Situational

Does it cause significant distress? Yes/No

General questions:
The sexual dysfunction is not explained by:
A non-sexual mental disorder Yes/No
Due to severe relationship distress or other psycho-social stressor Yes/No
Attributable to the effects of substance/medication or another medical condition Yes/No

CISR
Total score:
CMD: Yes/No

ICD-10 diagnosis:
Depressive episode: Yes/No
Dysthymia: Yes/No
OCD: Yes/No
GAD: Yes/No
Phobic anxiety disorder: Yes/No
Panic disorder: Yes/No
Non-organic insomnia: Yes/No