ANCZ01 For Prostate Cancer Patients Only - Prostate AUA/SHIM Questionnaire

AUA BPH SYMPTOM SCORE QUESTIONNAIRE

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

ALL THESE QUESTIONS PERTAIN TO THE PAST MONTH

How often have you had sensation of not emptying bladder completely after you finished urinating?

Not at all (0)

Less than 1 in 5 times (1)

Less than half the time (2)

About half the time (3)

More than half the time (4)

Almost Always (5)

How often have you had to urinate again less than 2 hours after you finished urinating?

Not at all (0)

Less than 1 in 5 times (1)

Less than half the time (2)

About half the time (3)

More than half the time (4)

Almost Always (5)

How often have you stopped and started again several times when you urinated?

Not at all (0)

Less than 1 in 5 times (1)

Less than half the time (2)

About half the time (3)

More than half the time (4)

Almost Always (5)

How often have you found it difficult to postpone urination?

Not at all (0)

Less than 1 in 5 times (1)

Less than half the time (2)

About half the time (3)

More than half the time (4)

Almost Always (5)

How often have you had a weak urinary stream

Not at all (0)

Less than 1 in 5 times (1)

Less than half the time (2)

About half the time (3)

More than half the time (4)

Almost Always (5)

How often have you had to push or strain

Not at all (0)

Less than 1 in 5 times (1)

Less than half the time (2)

About half the time (3)

More than half the time (4)

Almost Always (5)

How many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning?

None (0)

1 Time (1)

2 Times (2)

3 Times (3)

4 Times (4)

5+ (5)

Total Symptom Score

1-7 Mild 8-19 Moderate 20-35 Severe

SEXUAL HEALTH INVENTORY FOR MEN (SHIM)

Sexual health is an important part of an individual’s physical and emotional well-being. Erectile dysfunction (ED), also known as impotence, is a very common condition affecting sexual health. This questionnaire is designed to help you, and your doctor identify if you may be experiencing ED. If you are not sexually active, please skip this portion.

Please circle the number of response that best describes your own situation. Select only one response to each question.

OVER THE PAST 6 MONTHS

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

Very Low (1)

Low (2)

Moderate (3)

High (4)

Very High (5)

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

No sexual activity (0)

Almost never or never (1)

A few times (less than half the time) (2)

Sometimes (about half the time) (3)

Most times (more than half the time) (4)

Almost always or Always (5)

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

Did not attempt (0)

Almost never or never (1)

A few times (less than half the time) (2)

Sometimes (about half the time) (3)

Most times (more than half the time) (4)

Almost always or Always (5)

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

Did not attempt (0)

Extremely Difficult (1)

Very Difficult (2)

Difficult (3)

Slightly Difficult (4)

Not Difficult (5)

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

Did not attempt (0)

Almost never or never (1)

A few times (less than half the time) (2)

Sometimes (about half the time) (3)

Most times (more than half the time) (4)

Almost always or Always (5)

Total

1-7 Severe 8-11: Moderate 12-16: Mild to Moderate 17-21: Mild