Questionnaire
K. These Questions Are About Some Aspects of Sexual Expression You May Have Experienced in the Past Year and About Sexual Concerns and Problems.

In Question 1, indicate which of the items you have experienced in the past year by check the box that indicates how often you experienced it. Skip any you have not experienced.

RAR= Rarely

ST = Sometimes

0FT = often

ALL = All the time

 

 

(check any that apply):

1a. have experienced the following in the last year		RAR	ST	OFT	ALL
1	Difficulty finding a partner I wanted to be sexual with
2	Lower sexual desire than I wanted to have
3	Being too tired to have sex
4	Being too busy to have sex
5	Not feeling sexually satisfied
6	My partner not as interested in sex as I was
7	My partner less interested in closeness after sex than
8	My partner choosing inconvenient times for sex
1b. During sex in the last year I have experienced:
9	Difficulty getting excited/aroused
10	Feeling distracted
11	Inability to relax
12	Involuntary vaginal spasm so that vaginal entry and/or intercourse was impossible or difficult
13	Insufficient vaginal lubrication
14	Pain during intercourse or other internal stimulation
15	Fantasizing that I am having sex with someone other than my partner
16	Difficulty in reaching orgasm
17	Inability to have an orgasm
18	Reaching orgasm too quickly
19	My partner seeming distracted
20	My partner wanting shorter foreplay than wanted
21	My partner having difficulty getting aroused
22	My partner ejaculating too quickly
23	My partner having difficulty getting and/or maintaining an erection
24	Other (specify):
25	None of the above

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Some of the items in Question 1 you may think of as "the way life is." Others you may think of as "problems." 2. I think or thought of these items I marked in Question 1 as problems (Please write the number(s) of those items here or circle 0 for none):                                                    0 3. In the past year I have sought the following kinds of help for sexual concerns or problems (check all that apply):

 

 

 

 

 

1	None
2	Talked to my partner
3	Talked to a (nonpartner) friend
4	Talked to a relative
5	Talked to a minister or teacher
6	Read a book or article that gave advice
7	Went to a medical/health practitioner (other than a therapist)
8	Went to a therapist by myself
9	Went to a therapist with my partner
10	Enrolled in a course or program
11	Other (specify):

 

 

 

 

 

 

 

4 a. In the past year, my most important sexual problem or concern was (write the number from the list in Question 1 or specify) If None, circle 0 and skip 4b and 4c.

0

 

b. This problem or concern has been satisfactorily resolved

1

2

3

4

5

6

7

0

 

 

If the situation is not improved, circle 0 and skip 4c.

0

 

c. I attribute the improvement in this situation to (check all that apply):

1	A solution I figured out for myself
2	Talking with my partner
3	Talking with a friend, relative, parent, or minister
4	Seeing a therapist
5	Seeing a medical/health practitioner
6	Surgery
7	Medication (starting, stopping, changing)
8	Passage of time
10	Advice in a book or article
11	Getting a new partner
12	Other (PLEASE SPECIFY):