Version 1: Built using the Squarespace “form builder.” This allows users to interact with the form but there is no option for this kind of form without a “Submit” button. That means, no matter what, you will have a call to action that invites the user to email the office and submit their answers. I guess this isn’t really so different from telling users to “Contact” the office. The form would be sent to “info@katekass.com” and we could change the language to say that in whatever way makes the most sense to you. This version could be a stand alone page, could be pasted into the pages that make the most sense. Another option would be to have it set up as a pop up window (SEE VERSION 2)

SEXUAL HEALTH INVENTORY FOR MEN (SHIM)

INSTRUCTIONS

EACH QUESTION HAS 5 POSSIBLE RESPONSES. CHOOSE THE NUMBER THAT BEST DESCRIBES YOUR OWN SITUATION. SELECT ONLY 1 ANSWER FOR EACH QUESTION.

OVER THE PAST 6 MONTHS:

Version 2: This would be similar to the above version, but it would be a pop up. There are some limitations with formatting when done this way and rather than build the form all over again, I just have a couple of sample questions here so you can get the idea. This button could be added to the site wherever you would like. The biggest disadvantage is that these forms are time-consuming to build and they always require a “submit” button of some kind.

Version 3: This survey is set up like a normal web page with a call to make an appointment and a link to the contact page. It could be a standalone page that we link to from various other pages on your sites OR it could be pasted into the pages where you want it (tho I think it is a bit too long for that and would be better as a stand alone page if we decide to use this version of the survey). The biggest advantage of this version is that we have more control over the formating. The biggest disadvantage is that it is not interactive.

Sexual Health Inventory For Men (SHIM)

Instructions

Each question has 5 possible responses. Choose the number that best describes your own situation. Select only 1 answer for each question.

Over the past 6 months:

How do you rate your confidence that you could keep an erection?

1 - Very Low
2 - Low
3 - Moderate
4 - High
5 - Very High

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

1 - Almost never
2 - A few times
3 - Sometimes
4 - Most times
5 - Almost always or Always

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

1 - Almost never
2 - A few times
3 - Sometimes
4 - Most times
5 - Almost always or Always

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

1 Almost never
2 A few times
3 Sometimes
4 Most times
5 Almost always or Always

Scoring instructions

Add the numbers corresponding to the answers for questions 1 through 5. If Your score is 21 or less, erectile dysfunction (ED) should be addressed.

22-25: No ED
17-21: Mild ED
12-16: Mild-to-moderate ED
8-11: Moderate ED
5-7: Severe ED

If you are plagued by symptoms of erectile dysfunction, contact our office to discuss a thorough evaluation and to learn about the most progressive treatment options for ED.