Date of Scheduled Appointment

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* 1. Date of Scheduled Appointment

Date
Full Name 

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* 2. Full Name 

Date of Birth

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* 3. Date of Birth

Date of Birth
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.

Question Title

* 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?
2. How often did you feel unhappy about your sexual relationship?
3. How often did you feel guilty about your sexual difficulties?
4. How often did you feel frustrated by your sexual problems?
5. How often did you feel stressed about sex?
6. How often did you feel inferior because of sexual problems?
7. How often did you feel worried about sex?
8. How often did you feel sexually inadequate?
9. How often did you feel regrets about your sexuality?
10. How often did you feel embarrassed about sexual problems?
11. How often did you feel dissatisfied with your sex life?
12. How often did you feel angry about your sex life?
13. How often did you feel bothered by low desire?

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