I-PSS & SHIM Form

I-PSS & SHIM

International Prostate Symptom Score (IPSS) Sexual Health Inventory for Men (SHIM)

Phone
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First Name*
Last Name*
Email*
Date of Birth*
Month
Day
Year
Patient Instructions
Each question has several possible responses.
Select the number of the response that best describes your own situation.
Please be sure that you select a response for each question.

1. Incomplete Emptying*
In the last month, how often have you had the sensation of not emptying your bladder?
2. Frequency*
In the last month, how often have you had to urinate less than every two hours?
3. Intermittency*
In the last month, how often have you found you stopped and started again several times when you urinated?
4. Urgency*
In the last month, how often have you found it difficult to postpone urination?
5. Weak Stream*
In the last month, how often have you had a weak urinary stream?
6. Straining*
In the last month, how often have you had to strain to start urination?
7. Nocturia*
In the last month, how many times did you typically get up at night to urinate?
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Your Total IPSS Score is:
Score 1-7 Mild, 8-19 Moderate, 20-35 Severe
Quality of Life Due to Urinary Symptoms*
If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?
Sexual health is an important part of an individual's overall physical and emotional well-being. Erectile dysfunction, also known as impotence, is one type of very common medical condition affection sexual health. Fortunately, there are many different treatment options for erectile dysfunction. This questionnaire is designed to help you and your doctor identify if you may be experiencing erectile dysfunction. If you are, you may choose to discuss treatment options with your doctor. Each question has several possible responses. Select the response that best describes your own situation. Please be sure that you select a response for each questions.
1. How do you rate your confidence that you could keep an erection?*
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?*
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?*
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?*
5. When you attempted sexual intercourse, how often was it satisfactory for you?*
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You Total SHIM Score Is:
This information, including the question, structure and completeness of the sample survey, is based on forms and/or scoring systems developed by independent organizations of relevance to the diagnosis and treatment of benign prostatic hyperplasia (BPH). This material is not a substitute for a consultation or physical examination by a physician.

Dr. Aaron Kovaleski, MD

Kendra Payne, FNP-BC

Kyle Odvody, MS, FNP-BC

Greg Charleston, AGACNP-BC

Arterial Disease

Women's Health

Men's Health

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Venous Issues

Liver Cancer

Non-Healing Wounds

Cosmetic

I-PSS & SHIM Form

I-PSS & SHIM

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