SHIM Form

If you would prefer to download and print a PDF version of this form, please Click Here
First Name*
Last Name*
Email*
Date of Birth*
Patient Instructions
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?*
Hidden
The TOTAL SHIM Score is:
Score 1-7 Severe ED, 8-11 Moderate ED, 12-16 Mild to Moderate ED, 17-21 Mild ED
This information, including the questions, 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.
Name
This field is for validation purposes and should be left unchanged.

The Circulatory System Demystified: Understanding the Differences Between Arterial and Venous Issues and How to Treat Them Effectively

05/03/2023

If you’ve been experiencing unexplained swelling, pain, or a sluggish feeling in your lower limbs, it might be time to take a closer look at the … Continue Reading

Role of Interventional Radiology in Treating Pelvic Congestion Syndrome

04/19/2023

Pelvic Congestion Syndrome (PCS) is a common medical condition that affects women of reproductive age, caused by the enlargement of veins in the … Continue Reading

Fibroids and Fertility: Understanding Uterine Fibroid Tumors and Their Impact on Reproductive Health

03/08/2023

Uterine fibroids are non-cancerous growths of the uterus that can have a major impact on the reproductive system. For many women, these benign tumors … Continue Reading

img.wp-smiley,img.emoji{display:inline !important;border:none !important;box-shadow:none !important;height:1em !important;width:1em !important;margin:0 .07em !important;vertical-align:-.1em !important;background:none !important;padding:0 !important;}#gform_2 .gform_fileupload_multifile{display:none;}#gform_1 .gform_fileupload_multifile{display:none;}#gform_3 .gform_fileupload_multifile{display:none;}#gform_4 .gform_fileupload_multifile{display:none;}#gform_5 .gform_fileupload_multifile{display:none;}#gform_7 .gform_fileupload_multifile{display:none;}#gform_9 .gform_fileupload_multifile{display:none;}#gform_8 .gform_fileupload_multifile{display:none;}#gform_13 .gform_fileupload_multifile{display:none;}#gform_14 .gform_fileupload_multifile{display:none;}#gform_21 .gform_fileupload_multifile{display:none;}#gform_22 .gform_fileupload_multifile{display:none;}#gform_23 .gform_fileupload_multifile{display:none;}.header-image .site-title > a{background:url("https://cdn-bflna.nitrocdn.com/CijJFQciAtYHJnDWYhtYzEjnLRRHlEhH/assets/images/optimized/rev-993aa4a/wp-content/uploads/2021/02/ECCO-Medical-Logo-blue.png") left 50% no-repeat;background-size:contain;height:200px;}.header-image .site-title > a.nitro-lazy{background-image:none !important;}a.bluelink{color:#0a245f;text-decoration:none;font-weight:bold;}#text-9{max-width:300px;float:right;text-align:right;}#text-9 > div > div > p > a{padding:10px;text-align:right !important;}.before-site-header-widget .widget.simple-social-icons{float:left !important;}#text-8{max-width:770px;}@media only screen and (max-width: 500px){#text-9 > div > div > p > a{text-align:center !important;}#text-9{text-align:center;max-width:500px;}#text-8 > div > div > div{text-align:center;}}@media only screen and (max-width: 1200px){.archive-description img.size-large,.wp-post-image{max-width:70% !important;display:none !important;}}@media only screen and (max-width: 1366px){#text-8{max-width:740px !important;}}.gsection_description{font-size:18px !important;color:#28a2a3;}.greenbtn{display:inline-block;font-size:24px;font-weight:700;color:#fff !important;padding:20px 30px;border:6px solid #fff;border-radius:40px;background:#8cb362;line-height:1;text-decoration:none;text-shadow:none !important;}@media only screen and (max-width: 760px){.wrap,.site-inner .content-sidebar-wrap{width:100% !important;max-width:90% !important;margin-left:5vw !important;margin-right:auto;}.archive-description img.size-large,.wp-post-image{max-width:70% !important;}.archive-description img.size-large,.wp-post-image{max-width:70% !important;}.testimony{margin:40px 3vw 60px;}h3.accordion{font-size:100%;}h2{font-size:24px;margin-left:4vw;}}@media only screen and (max-width: 1200px){.entry-title{font-size:28px;margin-left:3vw;}.archive-description img.size-large,.wp-post-image{max-width:70% !important;}.testimony{margin:40px 3vw 60px;}h3.accordion{font-size:100%;}h2{font-size:24px;margin-left:4vw;}}.header-image .site-title > a{float:left;width:100%;background-repeat:no-repeat !important;background-position:left -3% !important;margin-bottom:-150px;text-indent:-9000px;}.header-image .site-title > a{background:url("https://cdn-bflna.nitrocdn.com/CijJFQciAtYHJnDWYhtYzEjnLRRHlEhH/assets/images/optimized/rev-993aa4a/wp-content/uploads/2021/02/ECCO-Medical-Logo-blue.png") left 50% no-repeat;background-size:contain;height:50px;}.header-image .site-title > a.nitro-lazy{background-image:none !important;}.archive-description img.size-large,.wp-post-image{max-width:50%;}.gform_anchor::before{content:"";display:block;width:0;height:50px;margin:-50px 0 0;}.ebookform{display:block;width:100%;height:auto;border:10px solid #8cb362;border-radius:20px;background-color:#fff;margin:auto;font-size:1.15em;margin-left:auto;color:#0a245f;font-family:"orkney",sans-serif;font-weight:700;}.ebimg{display:inline-block;float:left;width:24%;height:auto;margin:auto;padding-top:6%;}.ebsub{display:inline-block;width:76%;height:auto;float:left;}.ebimg::after{clear:both;}.ebookhero{margin:0 !important;width:100% !important;padding:3%;background-color:rgba(10,35,96,.16);}#gform_submit_button_15{background:#0a245f;border:none;border-radius:28px;color:#fff;cursor:pointer;font-size:1.15em;font-weight:700;line-height:1.2em;padding:10px 20px;text-transform:uppercase;text-decoration:none !important;width:auto;outline:none;}.evidre{display:inline-block;float:left;padding:2%;width:40%;}.epromo{display:inline-block;padding:2%;width:60%;margin-top:5%;}.sympt,.videoprev,.ebpromo-pad{display:inline-block !important;float:left;padding:2%;width:50% !important;}.v-center-content{margin:auto;}@media only screen and (max-width: 760px){.evidre{display:block;width:100%;}.epromo{display:block;width:100%;}.videoprev,.sympt,.ebpromo-pad{display:block !important;width:100% !important;}}#float-cta{position:fixed;top:200px;left:90%;z-index:1000;}#float-cta{text-transform:uppercase;text-align:center;font-size:14px;font-weight:700;padding:12px 15px;background:#0a245f;color:#fff;line-height:1;letter-spacing:-.015em;border-radius:20px;margin:0 0 0 5px;border-bottom:none;width:110px;}#float-cta .cta-btn a,#float-cta a{text-decoration:none !important;}#float-cta:hover{background:#8cb362;}@media only screen and (max-width: 760px){#float-cta{left:80%;top:600px;}}@media only screen and (max-width: 460px){#float-cta{left:60%;top:400px;}}.sympt-srv{padding:2% !important;}.gform_anchor{border:none !important;}#testi-page{display:-webkit-flex;display:flex;}.testi-feed,.testi-vid{padding:2%;width:50%;}.testi-feed{-webkit-order:1;-order:1;}.testi-vid{-webkit-order:2;-order:2;}@media only screen and (max-width: 760px){.testi-feed,.testi-vid{padding:2%;width:100% !important;}#testi-page{flex-direction:column-reverse;}}.row-cta{margin-top:2em;color:#fff !important;}.row-cta-inside h3{color:#fff !important;}.row-cta-inside h3 a:active,.row-cta-inside h3 a:visited{color:#fff !important;text-decoration:none;}.row-cta-inside h3 a:hover{color:#8cb362 !important;}.gsurvey-rating:not(:checked) > label:hover,.gsurvey-rating:not(:checked) > label:hover ~ label{background-image:url("https://cdn-bflna.nitrocdn.com/CijJFQciAtYHJnDWYhtYzEjnLRRHlEhH/assets/images/optimized/rev-993aa4a/wp-content/uploads/2022/10/ecco-star2.svg") !important;}.gsurvey-rating:not(:checked) > label:hover.nitro-lazy,.gsurvey-rating:not(:checked) > label:hover ~ label.nitro-lazy{background-image:none !important;}.gsurvey-rating > input:checked ~ label{background-image:url("https://cdn-bflna.nitrocdn.com/CijJFQciAtYHJnDWYhtYzEjnLRRHlEhH/assets/images/optimized/rev-993aa4a/wp-content/uploads/2022/10/ecco-star1.svg") !important;}.gsurvey-rating > input:checked ~ label.nitro-lazy{background-image:none !important;}.gsurvey-rating:not(:checked) > label{background-image:url("https://cdn-bflna.nitrocdn.com/CijJFQciAtYHJnDWYhtYzEjnLRRHlEhH/assets/images/optimized/rev-993aa4a/wp-content/uploads/2022/10/ecco-star0.svg") !important;}.gsurvey-rating:not(:checked) > label.nitro-lazy{background-image:none !important;}.gsurvey-rating:not(:checked) > label,.gsurvey-rating:not(:checked) > label:hover,.gsurvey-rating:not(:checked) > label:hover ~ label,.gsurvey-rating:not(:checked) > label,.gsurvey-rating:not(:checked) > label:hover,.gsurvey-rating:not(:checked) > label:hover ~ label,.gsurvey-rating > input:checked ~ label{width:65px;line-height:50px;background-size:50px 50px;color:rgba(221,221,221,0) !important;}.womac-sec .gsection_description{color:#0a245f !important;font-family:"orkney",sans-serif !important;font-weight:700 !important;line-height:1.2 !important;margin:0 0 20px 0 !important;}.gform_wrapper.gravity-theme .gsection{border-bottom:none !important;border-top:1px solid #ccc;padding:0 16px 8px 0;}.gchoice .gchoice_22_7_,.gchoice{display:inline-block !important;padding-left:2% !important;}.gform_wrapper.gravity-theme .gfield-choice-input + label{max-width:calc(100% - 12px) !important;}#field_22_4{text-align:center !important;}#simple-social-icons-3 ul li a,#simple-social-icons-3 ul li a:hover,#simple-social-icons-3 ul li a:focus{background-color:#0a245f !important;border-radius:20px;color:#fff !important;border:0px #fff solid !important;font-size:12px;padding:6px;}#simple-social-icons-3 ul li a:hover,#simple-social-icons-3 ul li a:focus{background-color:#8cb362 !important;border-color:#fff !important;color:#fff !important;}#simple-social-icons-3 ul li a:focus{outline:1px dotted #8cb362 !important;}