Southern Institute for Women's Sexual Health
Sexual Distress Scale

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* 1. Date of Scheduled Appointment

Date

Date

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* 2. Full Name

First Name

Last Name

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* 3. Date of Birth

Date of Birth

Date

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* 4. Below is a list of feelings and problems that men and women sometimes have concerning their sexuality. Please read over each item carefully and select the option that best describes how often that problem has bothered you or caused distress over the last four weeks. Please select only one option per item, and take care not to skip any items.

	Never	Rarely	Occasionally	Frequently	Always
1. How often did you feel distressed about your sex life?	1. How often did you feel distressed about your sex life? Never	1. How often did you feel distressed about your sex life? Rarely	1. How often did you feel distressed about your sex life? Occasionally	1. How often did you feel distressed about your sex life? Frequently	1. How often did you feel distressed about your sex life? Always
2. How often did you feel unhappy about your sexual relationship?	2. How often did you feel unhappy about your sexual relationship? Never	2. How often did you feel unhappy about your sexual relationship? Rarely	2. How often did you feel unhappy about your sexual relationship? Occasionally	2. How often did you feel unhappy about your sexual relationship? Frequently	2. How often did you feel unhappy about your sexual relationship? Always
3. How often did you feel guilty about your sexual difficulties?	3. How often did you feel guilty about your sexual difficulties? Never	3. How often did you feel guilty about your sexual difficulties? Rarely	3. How often did you feel guilty about your sexual difficulties? Occasionally	3. How often did you feel guilty about your sexual difficulties? Frequently	3. How often did you feel guilty about your sexual difficulties? Always
4. How often did you feel frustrated by your sexual problems?	4. How often did you feel frustrated by your sexual problems? Never	4. How often did you feel frustrated by your sexual problems? Rarely	4. How often did you feel frustrated by your sexual problems? Occasionally	4. How often did you feel frustrated by your sexual problems? Frequently	4. How often did you feel frustrated by your sexual problems? Always
5. How often did you feel stressed about sex?	5. How often did you feel stressed about sex? Never	5. How often did you feel stressed about sex? Rarely	5. How often did you feel stressed about sex? Occasionally	5. How often did you feel stressed about sex? Frequently	5. How often did you feel stressed about sex? Always
6. How often did you feel inferior because of sexual problems?	6. How often did you feel inferior because of sexual problems? Never	6. How often did you feel inferior because of sexual problems? Rarely	6. How often did you feel inferior because of sexual problems? Occasionally	6. How often did you feel inferior because of sexual problems? Frequently	6. How often did you feel inferior because of sexual problems? Always
7. How often did you feel worried about sex?	7. How often did you feel worried about sex? Never	7. How often did you feel worried about sex? Rarely	7. How often did you feel worried about sex? Occasionally	7. How often did you feel worried about sex? Frequently	7. How often did you feel worried about sex? Always
8. How often did you feel sexually inadequate?	8. How often did you feel sexually inadequate? Never	8. How often did you feel sexually inadequate? Rarely	8. How often did you feel sexually inadequate? Occasionally	8. How often did you feel sexually inadequate? Frequently	8. How often did you feel sexually inadequate? Always
9. How often did you feel regrets about your sexuality?	9. How often did you feel regrets about your sexuality? Never	9. How often did you feel regrets about your sexuality? Rarely	9. How often did you feel regrets about your sexuality? Occasionally	9. How often did you feel regrets about your sexuality? Frequently	9. How often did you feel regrets about your sexuality? Always
10. How often did you feel embarrassed about sexual problems?	10. How often did you feel embarrassed about sexual problems? Never	10. How often did you feel embarrassed about sexual problems? Rarely	10. How often did you feel embarrassed about sexual problems? Occasionally	10. How often did you feel embarrassed about sexual problems? Frequently	10. How often did you feel embarrassed about sexual problems? Always
11. How often did you feel dissatisfied with your sex life?	11. How often did you feel dissatisfied with your sex life? Never	11. How often did you feel dissatisfied with your sex life? Rarely	11. How often did you feel dissatisfied with your sex life? Occasionally	11. How often did you feel dissatisfied with your sex life? Frequently	11. How often did you feel dissatisfied with your sex life? Always
12. How often did you feel angry about your sex life?	12. How often did you feel angry about your sex life? Never	12. How often did you feel angry about your sex life? Rarely	12. How often did you feel angry about your sex life? Occasionally	12. How often did you feel angry about your sex life? Frequently	12. How often did you feel angry about your sex life? Always
13. How often did you feel bothered by low desire?	13. How often did you feel bothered by low desire? Never	13. How often did you feel bothered by low desire? Rarely	13. How often did you feel bothered by low desire? Occasionally	13. How often did you feel bothered by low desire? Frequently	13. How often did you feel bothered by low desire? Always