Questionnaire
L.
The Next Questions Are About Your Body.
1. Overall, I am satisfied with how my body looks.
Strongly Disagree Strongly Agree N/A
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| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
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2. My current or last partner is/was satisfied
with how my body looks.
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
3. My feelings about my body interfere with my
sexual satisfaction.
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
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4 a. My weight is ________ pounds.
b. My height is __ feet__ inches.
5 a. I have had the following surgery.
(Please check those you have had and write in your
age at the time of the surgery):
| |
Age at time of surgery
|
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| Hysterectomy (uterus removed) |
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| Ovaries removed |
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| Mastectomy |
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Other surgery (please specify)
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| b. I have
the following physical condition(s) |
Please mark and indicate your age when the condition began.
Age of onset
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| Diabetes |
|
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| Chronic vaginal dryness
(currently) |
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| Chronic bladder infections
(currently) |
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Other illness, disability, or physical condition (please
specify)
|
|
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| None |
|
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| 6. In the past
year I have taken the following medications or hormones |
| Please mark
and indicate the number of years taken. |
No. of Years Taken
|
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| Blood pressure
medication |
|
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| Antihistamine |
|
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| Antidepressant |
|
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| Antianxiety
medication |
|
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| Insulin |
|
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| Birth control
pills |
|
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| Other estrogen |
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| Other progestin/progesterone |
|
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| Other medications
or hormones (Please specify) |
|
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| None |
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7. The physical condition of my body interferes with my sexual satisfaction.
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
Answer Question 8 only if you are not now physically
able to become pregnant. Give ages for all you have experienced:
8. I am not physically able to become pregnant because
(give ages for all that apply):
I reached menopause at age________.
I had my tubes tied when I was age _________.
I had a hysterectomy when I was age____________.
I had/have had endometriosis from approximately age________.
I had a pelvic infection when I was age________.
Other (please specify):_______________.
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Remember
The questionnaire is here for VIEWING ONLY.
Please DO NOT send your answers to me.
Copyright 1998, Carol Ellison, Ph.D.
