Sexual Health Inventory for Men Self Assessment Form The IIEF-5 Questionnaire (SHIM) Over the past 6 months: Name Email Age How do you rate your confidence that you could get and keep an erection? Please select your answer Very low Low Moderate High Very High When you had erections with sexual stimulation, how often were your erections hard enough for penetration? Please select your answer Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner? Please select your answer Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? Please select your answer Extremely difficult Very difficult Difficult Slightly difficult Not difficult When you attempted sexual intercourse, how often was it satisfactory for you? Please select your answer Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always Your Score : 1-7 : Severe ED 8-11 : Moderate ED 12-16 : Mild-moderate ED 17-21 : Mild ED 22-25 : No ED Time’s up Book an Appointment with Us Our state-of-the-art imaging, diagnostic and innovative technology Book Now
