Name
*
First Name
Last Name
Date of birth
*
MM
DD
YYYY
Over the past 4 weeks, how often did you feel sexual desire or interest?
Almost always or always
Most times (more than half the time)
Sometimes (about half the time)
A few times (less than half the time)
Almost never or never
Over the past 4 weeks, how would you rate your level (degree) of sexual desire or interest?
Very high
High
Moderate
Low
Very low or none at all
Over the past 4 weeks, how often did you feel sexually aroused ("turned on") during sexual activity or intercourse?
No sexual activity
Almost always or always
Most times (more than half the time)
Sometimes (about half the time)
A few times (less than half the time)
Almost never or never
Over the past 4 weeks, how would you rate your level of sexual arousal ("turn on") during sexual activity or intercourse?
No sexual activity
Very high
High
Moderate
Low
Very low or none at all
Over the past 4 weeks, how confident were you about becoming sexually aroused during sexual activity or intercourse?
No sexual activity
Very high confidence
High confidence
Moderate confidence
Low confidence
Very low or no confidence
Over the past 4 weeks, how often have you been satisfied with your arousal (excitement) during sexual activity or intercourse?
No sexual activity
Almost always or always
Most times (more than half the time)
Sometimes (about half the time)
A few times (less than half the time)
Almost never or never
Over the past 4 weeks, how often did you become lubricated ("wet") during sexual activity or intercourse?
No sexual activity
Almost always or always
Most times (more than half the time)
Sometimes (about half the time)
A few times (less than half the time)
Almost never or never
Over the past 4 weeks, how difficult was it to become lubricated ("wet") during sexual activity or intercourse?
No sexual activity
Extremely difficult or impossible
Very difficult
Difficult
Slightly difficult
Not difficult
Over the past 4 weeks, how often did you maintain your lubrication ("wetness") until completion of sexual activity or intercourse?
No sexual activity
Almost always or always
Most times (more than half the time)
Sometimes (about half the time)
A few times (less than half the time)
Almost never or never
Over the past 4 weeks, how difficult was it to maintain your lubrication ("wetness") until completion of sexual activity or intercourse?
No sexual activity
Extremely difficult or impossible
Very difficult
Difficult
Slightly difficult
Not difficult
Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you reach orgasm (climax)?
No sexual activity
Almost always or always
Most times (more than half the time)
Sometimes (about half the time)
A few times (less than half the time)
Almost never or never
Over the past 4 weeks, when you had sexual stimulation or intercourse, how difficult was it for you to reach orgasm (climax)?
No sexual activity
Extremely difficult or impossible
Very difficult
Difficult
Slightly difficult
Not difficult
Over the past 4 weeks, how satisfied were you with your ability to reach orgasm (climax) during sexual activity or intercourse?
No sexual activity
Very satisfied
Moderately satisfied
About equally satisfied and dissatisfied
Moderately dissatisfied
Very dissatisfied
Over the past 4 weeks, how satisfied have you been with the amount of emotional closeness during sexual activity between you and your partner?
No sexual activity
Very satisfied
Moderately satisfied
About equally satisfied and dissatisfied
Moderately dissatisfied
Very dissatisfied
Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner?
Very satisfied
Moderately satisfied
About equally satisfied and dissatisfied
Moderately dissatisfied
Very dissatisfied
Over the past 4 weeks, how satisfied have you been with your overall sexual life?
Very satisfied
Moderately satisfied
About equally satisfied and dissatisfied
Moderately dissatisfied
Very dissatisfied
Over the past 4 weeks, how often did you experience discomfort or pain DURING vaginal penetration?
Did not attempt intercourse
Almost always or always
Most times (more than half the time)
Sometimes (about half the time)
A few times (less than half the time)
Almost never or never
Over the past 4 weeks, how often did you experience discomfort or pain FOLLOWING vaginal penetration?
Did not attempt intercourse
Almost always or always
Most times (more than half the time)
Sometimes (about half the time)
A few times (less than half the time)
Almost never or never
Over the past 4 weeks, how would you rate your level (degree) of discomfort or pain during or following vaginal penetration?
Did not attempt intercourse
Very high
High
Moderate
Low
Very low or none at all