SHIM - Sexual Health Inventory for Men

Answer based on your activity over the last 4 weeks ....

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Name

First Name

Last Name

Date of Birth

YYYY

The current EMAIL that you use to log in the Focalyx App

The following responses apply

1- On my Own 2- When I use - Viagra, Cialis, Levitra, Stendra, Staxyn 3- When I use Penile Injections

OWN

Oral MEDS

Injections

S1_How do you rate your confidence that you could get and keep an erection? IIEFQ15

1 Very low 2 Low 3 Moderate 4 High 5 Very high

S2_When you had erections with sexual stimulation, how often were your erections hard enough for penetration? IIEFQ2

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

S3_During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? IIEFQ4

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

S4_During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? IIEFQ5

0 Did not attempt intercourse 1 Extremely difficult 2 Very difficult 3 Difficult 4 Slightly difficult 5 Not difficult

S5_When you attempted sexual intercourse, how often was it satisfactory for you? IIEFQ7

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

OPTIONAL - How many times have you attempted sexual intercourse? IIEFQ6

0 No attempts 1 One to two attempts 2 Three to four attempts 3 Five to six attempts 4 Seven to ten attempts 5 Eleven or more attempts

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