Erectile Dysfunction (SHIM) Questionnaire
Could you have Erectile Dysfunction?
Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Email
example@example.com
1) How do you rate your confidence that you could get and keep an erection?
1- Very low
2- Low
3- Moderate
4- High
5- Very High
2) When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
0- No sexual activity
1- Almost never or never
2- A few times (Much less than half the time)
3- Sometimes (About half the time)
4- Most times (Much more than half the time)
5- Almost always or always
3) During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?
0- Did not attempt intercourse
1-Almost never or never
2- A few times (much less than half the time)
3- Sometimes (about half the time)
4- Most times (much more than half the time)
5- Almost always or always
4) During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
0- Did not attempt intercourse
1- Extremely difficult
2- Very difficult
3- Difficult
4- Slightly difficult
5- Not difficult
5) When you attempted sexual intercourse, how often was it satisfactory for you?
0- Did not attempt intercourse
1- Almost never or never
2- A few times (Much less than half the time)
3- Sometimes (About half the time)
4- Most times (Much more then half the time)
5- Almost always or always
Select Your Total Score
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Patient SHIM Score
Date
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Month
-
Day
Year
Date
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