SHIM FormIIEF-5 Questionnaire (SHIM)ED Questionnaire Email Address * How do you rate your confidence that you could get and keep an erection? Select1 - Very low2 - Low3 - Moderate4 - High5 - Very High When you had erections with sexual stimulation, how often were your erections hard enough for penetration? Select1 - Almost never or never2 - A few times (much less than half the time)3 - Sometimes (about half the time)4 - Most times (much more than half)5 - Almost always or always During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner? Select1 - Almost never or never2 - A few times (much less than half the time)3 - Sometimes (about half the time)4 - Most times (much more than half)5 - Almost always or always During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? Select1 - Extremely difficult2 - Very difficult3 - Difficult4 - Slightly difficult5 - Not difficult When you attempted sexual intercourse, how often was it satisfactory for you? Select1 - Almost never or never2 - A few times (much less than half the time)3 - Sometimes (about half the time)4 - Most times (much more than half)5 - Almost always or always Total Score: Submit Reset 1 - 7: Severe ED 8 - 11: Moderate ED 12 - 16: Mild-moderate ED 17 - 21: Mild ED 22 - 25: No ED WaveTech Greensboro 802 Green Valley Road #214 Greensboro, NC 27408(336) 908-0100greensboro@wavetechtherapy.com Client Intake Form SHIM FormMilitary Discount
