SEXUAL HEALTH INVENTORY FOR MEN

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?

Very low Low Moderate High Very high

1 2 3 4 5

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

No sexual
activity Almost never
or none A few times
(much less than
half the time) Sometimes
(about half
the time) Most times
(much more than
half the time) Almost always
or always

0 1 2 3 4 5

3. During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?

Did not attempt
intercourse Almost never
or none A few times
(much less than
half the time) Sometimes
(about half
the time) Most times
(much more than
half the time) Almost always
or always

0 1 2 3 4 5

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

Did not attempt
intercourse Extremely
difficult Very
difficult Difficult Slightly
difficult Not
difficult

0 1 2 3 4 5

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

Did not attempt
intercourse Almost never
or never A few times
(much less than
half the time) Sometimes
(about half
the time) Most times
(much more than
half the time) Almost always
or always

0 1 2 3 4 5

SCORE: __________
Add the numbers corresponding to questions 1 - 5. If your score is 21 or less, you may want to speak to your doctor.

No sexual activity	Almost never or none	A few times (much less than half the time)	Sometimes (about half the time)	Most times (much more than half the time)	Almost always or always
0	1	2	3	4	5

Did not attempt intercourse	Almost never or none	A few times (much less than half the time)	Sometimes (about half the time)	Most times (much more than half the time)	Almost always or always
0	1	2	3	4	5

Did not attempt intercourse	Extremely difficult	Very difficult	Difficult	Slightly difficult	Not difficult
0	1	2	3	4	5

Did not attempt intercourse	Almost never or never	A few times (much less than half the time)	Sometimes (about half the time)	Most times (much more than half the time)	Almost always or always
0	1	2	3	4	5