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How it works
Natural Supplements
FAQ
Contact Us
SHIM Questionnaire
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SHIM Questionnaire
SHIM Questionnaire for Men
Step
1
of
2
50%
1. How do you rate your confidence that you could get and keep an erection?
(Required)
1. Very low
2. 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 (entering your partner)?
(Required)
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?
(Required)
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
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
(Required)
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?
(Required)
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
Name
(Required)
First
Last
Email
(Required)
Phone
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
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