New Patient Medical History Form

Sexual Health Inventory for Men (SHIM)

As men age, it is common to develop prolonged sexual health conditions and to have questions about this important quality of life health condition. Complete this questionnaire to assess your sexual health. If needed, treatments are available for you.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email Address
example@example.com
Please answer the sexual health questions by selecting your answers below. Add up your score at the end.
How do you rate your confidence that you could get and keep an erection?*

1

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5

1 is , 5 is
When you had erections with sexual stimulation, how often were your erections hard enough for penetration?*

1

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5

1 is , 5 is
During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner?*

1

2

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4

5

1 is , 5 is
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?*

1

2

3

4

5

1 is , 5 is
When you attempted sexual intercourse, how often was it satisfactory for you?*

1

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1 is , 5 is
Total score*
The Sexual Health Inventory for Men (SHIM) classifies erectile dysfunction (ED) severity with the following breakpoints:

1-7: Severe ED

8-11: Moderate ED

12-16: Mid-moderate ED

17-21: Mild ED

22-25: No ED
Select any ED Treatments you have tried:

Pills/MedicationVacuum DeviceInjection TherapyMUSE™Other
If you are interested in discussing your assessment results and learning about durable treatment options, call (573) 499-4990 to make an appointment with one of our physicians or select "Yes" below.
Do you want us to contact you about an appointment*
What is your preferred method of contact?*
Please provide any additional information you would like to discuss at your appointment.
Should be Empty:

Sexual Health Inventory for Men (SHIM)