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SHIM score
|
Muscle Strength
|
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Mood and Cognition
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Back Problem/ Back Surgery/Back Injury
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Pelvic Pain/Pelvic Trauma
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Comments
|
|
Fatigue
|
Additional Information
|
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Alcohol Use
|
Additional Information
|
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Tobacco Use
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How many cigarettes per week
|
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When did you quit/ years of quitting tobacco
|
Additional Information
|
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Morning Erections
|
Additional Information
|
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Stress
|
Additional Information
|
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Anxiety
|
additional infomation
|
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Depression
|
Additional Information
|
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Heart Problem
|
Additional Information
|
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Headache/Migraine
|
Additional Information
|
|
Lifestyle
|
Additional Information
|
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Do you have kids
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Naturally conceived or artificially inseminated
|
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Any Previous Treatment for the same condition
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