Sexual Health Inventory For Men in Waterloo, IL | Regenerative Medicine Center of Southern California

PATIENT NAME:*

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TODAY’S DATE:*

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PATIENT INSTRUCTIONS

Sexual health is an important part of an individual's overall physical and emotional well-being. Erectile dysfunction, also known as impotence, is one type of very common medical condition affecting sexual health. Fortunately, there are many different treatment options for erectile dysfunction. This questionnaire is designed to help you and your doctor identify if you may be experiencing erectile dysfunction. If you are, you may choose to discuss treatment options with your doctor.

Each question has several possible responses. Circle the number of the response that best describes your own situation. Please be sure that you select one and only one response for each question.

OVER THE PAST 6 MONTHS:

How do you rate your confidence that you could get and keep an erection?*

When you had erections with sexual stimulation, how often were your erections hard enough for penetration (entering your partner)?*

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

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 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

During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?*

When you attempted sexual intercourse, how often was it satisfactory for you?*

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

Add the numbers corresponding to the last five questions. TOTAL:*

The Sexual Health Inventory for Men further classifies ED severity with the following breakpoints:

1-7 Severe ED 8-11 Moderate ED 12-16 Mild to
Moderate ED 17-21 Mild ED

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