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Colorado CyberKnife Sexual Health Inventory for Men (SHIM)

Page One

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 conditions affecting sexual health. Fortunately, there are many different treatment options for erectile dysfunction. This confidential questionnaire is designed to help you and your doctor identify if you may be experiencing erectile dysfunction. If you are, the responses you give will help you and your doctor choose the best possible treatment options.

Each question has several possible responses. Circle the number of the response that best describes your own situation.
Patient Information:
calendar
Over The Past Six Months:
1. How do you rate your confidence that you could get and keep an erection? *This question is required.
Very Low
1		Low
2		Moderate
3		High
4		Very High
5
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)? *This question is required.
No Sexual Activity
0		Almost Never or Never
1		A Few Times (much less than half the time)
2		Sometimes (about half the time)
3		Most Times (much more than half the time)
4		Almost Always or Always
5
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? *This question is required.
No Sexual Activity
0		Almost Never or Never
1		A Few Times (much less than half the time)
2		Sometimes (about half the time)
3		Most Times (much more than half the time)
4		Almost Always or Always
5
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? *This question is required.
Did Not Attempt Intercourse
0		Extremely Difficult
1		Very Difficult
2		Difficult
3		Slightly Difficult
4		Not Difficult
5
5. When you attempted sexual intercourse, how often was it satisfactory for you? *This question is required.
No Sexual Activity
0		Almost Never or Never
1		A Few Times (much less than half the time)
2		Sometimes (about half the time)
3		Most Times (much more than half the time)
4		Almost Always or Always
5
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