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.
Phone
This field is for validation purposes and should be left unchanged.

5 Things to Do If You’re at Risk for Peripheral Artery Disease