SHIM Questionnaire

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Erectile Dysfunction Services Offered In Irving, TX
Erectile dysfunction makes maintaining a healthy sexual connection with a partner challenging and leaves many men feeling out of touch with their bodies. The team at Vcare in Irving, Texas, have the expertise to explore the cause of erectile dysfunction and determine which treatment options offer the best solution.

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Name* This field is required.

First Name

Last Name

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Date of birth

Date

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1) How do you rate your confidence that you could get and keep an erection?* This field is required.MAKE A NOT OF YOUR # ANSWER IN EACH FOLLOWING QUESTION

1- Very low

2- Low

3- Moderate

4- High

5- Very High

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2) When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?* This field is required.

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

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3) During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?* This field is required.

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

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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

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5) When you attempted sexual intercourse, how often was it satisfactory for you?* This field is required.

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

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Sliders with calculated resultSLIDE YOUR NUMBER TO MATCH YOUR RESPONSE FOR EACH QUESTION

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Review your rating based on your response

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WHAT WAS YOUR NUMBER RESULT? * This field is required.Adjust the dial to your Score

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Select your Range 1-7 dosage below* This field is required.Tap tablet to confirm

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Select your Range 8-11 dosage below* This field is required.Tap tablet to confirm

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Select your Range 12-16 dosage below* This field is required.Tap tablet to confirm

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Select your Range 17-21 dosage below* This field is required.Tap tablet to confirm

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