SHIM Questionnaire Form
Please complete the SHIM Questionnaire Form by answering all questions below.
Age Group
*
Please Select
18–29
30–39
40–49
50–59
60–69
70 or older
How would you rate your confidence in your ability to achieve and maintain an erection?
*
Very low
Low
Moderate
High
Very high
When you had erections with sexual stimulation, how often were your erections firm enough for penetration?
*
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 your partner?
*
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?
*
Extremely difficult
Very difficult
Difficult
Slightly difficult
Not difficult
When you attempted sexual intercourse, how often was it satisfactory for you?
*
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
In the past month, how often did you feel satisfied with your sexual experience?
*
Never
Rarely
Sometimes
Often
Always
How would you rate your overall satisfaction with your sexual life?
*
1
2
3
4
5
Please indicate how much you agree with the following statements about your sexual experience in the past month.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I felt confident in my ability to perform sexually.
1
2
3
4
5
I was satisfied with the frequency of sexual activity.
6
7
8
9
10
My sexual experiences were pleasurable.
11
12
13
14
15
Is there anything else you would like to share about your experience?
Submit
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