First Name
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Last Name
*
Phone
*
Email
*
Sexual Health Inventory For Men (SHIM)
Over the past 6 months:
How do you rate your confidence that you could keep an erection?
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Very Low
Very
Moderate
High
Very High
When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?
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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 (entered) your partner
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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?
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Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult
When you attempted sexual intercourse, how often was it satisfactory for you?
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Almost never or never
A few times (much less than half the time)
Sometimes (About half the time )
Most times ( Much more then half the time )
Almost always or always