The IIEF-5 Questionnaire (SHIM) 
Please encircle the response that best describes you for the following five questions: 

Over the past 6 months: 1. How do you rate your confidence that you could get and keep an erection? 	Very low 1 	Low 2 	Moderate 3 	High 4 	Very high 5 	
2. When you had erections with sexual stimulation, how often were your erections hard enough for penetration? 	Almost never or never 1 	A few times (much less than half the time) 2 	Sometimes (about half the time) 3 	Most times (much more than half the time) 4 	Almost always or always 5 	
3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated your partner? 	Almost never of never 1 	A few times (much less than half the time) 2 	Sometimes (about half the time) 3 	Most times (much more than half the time) 4 	Almost always or always 5 	
4. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? 	Extremely difficult 1 	Very difficult 2 	Difficult 3 	Slightly difficult 4 	Not difficult 5 	
5. When you attempted sexual intercourse, how often was it satisfactory for you? 	Almost never or never 1 	A few times (much less than half the time) 2 	Sometimes (about half the time) 3 	Most times (much more than half the time) 4 	Almost always or always 5 	

Total Score: ___________________ 
1-7: Severe ED 8-11: Moderate ED    12-16: Mild-moderate ED      17-21: Mild ED 22-25: No ED