The IIEF-5 Questionnaire (SHIM)
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Over the past 6 months: 1-7: Severe ED 8-11: Moderate ED 12-16: Mild-moderate ED 17-21: Mild ED 22-25: No ED
Name
*
First
Last
Phone
*
Date / Time
*
Date
Time
How do you rate your confidence that you could get and keep an erection
*
Very Low
Low
Moderate
High
Very high
When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
*
Almost never or never
A few times
Sometimes
Most times
Almost always or always
During sexual intercourse, how often were you able erection after you had to maintain your penetrated your partner?
*
Almost never or never
A few times
Sometimes
Most times
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
Sometimes
Most times
Almost always or always
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