There is much that we know about sexual behavior of people suffering from dementia, but little is understood about how the caregiving partner deals with his/her own sexual needs in the face of dementia's impact on the relationship. This survey is to learn more about the changes that often occur in sexual intimacy between partners when one of the partners suffers from dementia or loss of memory. The survey is entirely anonymous, so please be frank with your answers. The results of the survey will be helpful to many partners of people with dementia. You may watch for a report by going to www.counselingnotes.wordpress.com. You may follow that blog in order to receive notices of new articles.

Thank you for your participation.

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* 1. My spouse/partner is diagnosed with:

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* 2. My gender

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* 3. My partner/spouse' gender

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* 4. My partner has been suffering from dementia symptoms for

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* 5. I and my partner/spouse have been together for

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* 6. Sexual intimacy with my spouse/partner is

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* 7. I believe

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* 8. My ideas about intimacy are informed by my spiritual or religious values

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* 9. How true is the following statement for you: It’s really hard for me to reconcile the two values of sexual fidelity and unmet sexual desires.

0 - Not hard at all 100 - It feels impossible to reconcile
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 10. What do you do to cope with the pain of loss from intimacy.

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