Questionnaire
P. This Section is About Your Contraceptive Method
Q. These 4 Questions Are About Sexually Transmitted
Diseases
P. THIS SECTION IS ABOUT
YOUR CONTRACEPTIVE METHOD:
If you do NOT use a contraceptive method, circle
0 and skip to Section Q.
0
1 a. The method of contraception I use most frequently
is (PLEASE WRITE IN): ______________
b. This method increases my sexual satisfaction.
Strongly Disagree Strongly Agree N/A
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| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
Q. THESE 4 QUESTIONS ARE
ABOUT SEXUALLY TRANSMITTED DISEASE
1. I have at some time in my life contracted a sexually
transmitted disease (STD.)
Yes No
(IF YES, PLEASE SPECIFY WHAT IT WAS):_______________________
If you DO NOT use a method of disease protection,
circle 0 and skip to Question:
0
3. Note the instructions above
Question 3.
2 a. The method of protection against sexually transmitted
diseases I use most frequently is"
(PLEASE WRITE IN):_______________________________________________________
b. This method increases my sexual satisfaction
|
STRONGLY DISAGREE
|
|
|
|
|
|
STRONGLY AGREE
|
N/A
|
|
1
|
2 |
3 |
4 |
5 |
6 |
7
|
0
|
If you have NOT had sex with a partner in the last
3 months, please circle 0 and skip to section R.
0
3. In sex with my partner(s) during the last 3 months
I have felt concerned that I might get an STD.
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
4. In sex with my partner(s) during the last 3 months
I have felt concerned that
I might transmit an STD.
Strongly Disagree Strongly Agree N/A
|
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
0 |
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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.
