Department of Urologic Surgery SHIM/EHQ/IIEF-15 Erectile Function Questionnaire Date: ________/________/________ | |
Over the past four weeks:
How would you rate your confidence that you could get and keep an erection?
1 Very low
Low
3 Moderate
4 High
5 Very high
2) When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
0 No sexual activity
1 Almost never/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/always
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/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/always
4) 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/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/always
6) When you attempted sexual intercourse, did you experience…
0 No increase in penile size or hardness
1 Increase in size but not hard
2 Hard, but not hard enough for penetration
3 Hard enough for penetration (but not completely hard)
4 Completely hard
7) How often were you able to get an erection during sexual activity?
0 No sexual activity
1 Almost never/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/always
8) When you attempted sexual intercourse, how often were you able to penetrate (enter) your partner?
0 Did not attempt intercourse
1 Almost never/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/always
9) How many times have you attempted sexual intercourse?
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
10) How much have you enjoyed sexual intercourse?
0 No intercourse
1 No enjoyment
2 Not very enjoyable
3 Fairly enjoyable
4 Highly enjoyable
5 Very highly enjoyable
11) When you had sexual stimulation or intercourse, how often did you ejaculate?
0 No sexual stimulation/intercourse
1 Almost never/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/always
12) When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax?
0 No sexual stimulation/intercourse
1 Almost never/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/always
13) How often have you felt sexual desire?
1 Almost never/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/always
14) How would you rate your sexual desire?
1 Very low/none at all
2 Low
3 Moderate
4 High
5 Very high
15) How satisfied have you been with your overall sex life?
1 Very dissatisfied
2 Moderately dissatisfied
3 About equally satisfied and dissatisfied
4 Moderately satisfied
5 Very satisfied
16) How satisfied have you been with your sexual relationship with your partner?
1 Very dissatisfied
2 moderately dissatisfied
3 About equally satisfied and dissatisfied
4 Moderately satisfied
5 Very satisfied
Sexual Health Inventory for Men (SHIM) = _______
Questions 1-5
Question 6 (EHQ) = _______
IIEF-15 =_______
Questions 1-5 and 7-16
Reference: Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A.
The international index of erectile function (IIEF) a multidimensional scale for assessment of erectile dysfunction. Urology. 1997 Jun; 49(6):822-30.
