IIEF-5 (SHIM)

Erectile Dysfunction Screening (IIEF-5)

Over the past 6 months, please answer the following:

Your answers are confidential and used only by your provider to guide care.

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

2. When you had erections with sexual stimulation, how often were they hard enough for penetration?

3. During sexual intercourse, how often were you able to maintain your erection after penetration?

4. During sexual intercourse, how difficult was it to maintain your erection to completion?

5. When you attempted intercourse, how often was it satisfactory?

Your Information

So we can match this to your chart and follow up.

Full name *Email *PhoneDate of birthAnything you'd like the provider to know?

Submitted securely. Used only for your care.

A-Nu Health · (312) 796-2646 · info@a-nuhealth.com — These responses are informational and reviewed by your provider. Not a diagnosis. If you are in crisis, call or text 988 or call 911.