This questionnaire can help you and your doctor determine if you have symptoms of ED (erectile dysfunction).

For each question, note your answer by circling the number that approximates your belief.
 Add your numbers together and refer to the table below to see what your score may mean.

Over the past six months . . .

  1. How do you rate your confidence that you could get and keep an erection?

1 Very low 2 Low
3 Moderate 4 High

5 Very high

  1. When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your part- ner)?

0 No sexual activity
1 Almost never or never
2 A few times (much less than half the time) 3 Sometimes (about half the time)
4 Most times (much more than half the time) 5 Almost always or always

3.During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?

0 Did not attempt intercourse
1 Almost never or never
2 A few times (much less than half the time) 3 Sometimes (about half the time)
4 Most times (much more than half the time) 5 Almost always or always

  1. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?

0 Did not attempt intercourse 1 Extremely difficult
 2 Very difficult 
3 Difficult

4 Slightly difficult 5 Not difficult

5.When you attempted sexual intercourse, how often was it satisfactory for you?

0 Did not attempt intercourse
1 Almost never or never
2 A few times (much less than half the time) 3 Sometimes (about half the time)
4 Most times (much more than half the time) 5 Almost always or always

Total:___________

SHIM Scores You may have . . .
1-7 Severe ED
8-11 Moderate ED
12-16 Mild to Moderate ED
17-21 Mild ED
22-25 No signs of ED