Sexual_Health_Inventory_Men

SEXUAL HEALTH INVENTORY FOR MEN
QUESTIONNAIRE:

Name:

Date:

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:

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

1- Very low

2- Low

3- Moderate

4- High

5- High

2. 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 the time)

3- Sometimes (about half 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 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

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 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

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Calculate Score Total by adding up the number circled for each
question.

SCORE TOTAL =

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