test_form_page SHIM/IIEF Assessment 5-question erectile dysfunction assessment. "(Required)" indicates required fields 123456 How would you rate your confidence that you could get and maintain an erection?(Required) Very Low Low Moderate High Very High When you had erections with sexual stimulation, how often were your erections hard enough for penetration?(Required) Almost Never / 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 / Always During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner?(Required) Almost Never / 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 / Always During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?(Required) Extremely Difficult Very Difficult Difficult Slightly Difficult Not Difficult When you attempted sexual intercourse, how often was it satisfactory for you?(Required) Almost Never / 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 / Always Name(Required) First Last Email(Required) Phone(Required)BIRTH DATE MM slash DD slash YYYY Which location would you like to contact?Select a LocationPlantationBoca RatonFort MyersNaplesPalm Beach GardensCoral GablesHow did you hear about us?– Fill Out Other Fields –REFERENCES Rosen RC, Cappelleri JC, Smith MD, Lipsky J, Peña BM. Development and evaluation of an abridged, 5-item version of the International Index of Erectile Function (IIEF-5) as a diagnostic tool for erectile dysfunction. International Journal of Impotence Research 1999, 11 (6): 319-26At Atlantic Men's Clinic, we're serious about your privacy. By submitting this form you expressly consent that Atlantic Men's Clinic may contact you via any phone number(s) provided using automatic telephone dialing systems, SMS texts, and/or prerecorded messages to help with processing your request. For more information regarding the Telephone Consumer Protection Act click here.Hiddenutm_campaign_url Hiddenutm_referrer NameThis field is for validation purposes and should be left unchanged.