Questionnaire

1. Instructions for Survey

Hello,

When you fill out this survey, the answers are directly written into an HIPAA compliant, encrypted computer, and not stored anywhere else. This is the highest degree of privacy in medical record keeping. All personal information will be kept confidential.

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Female Sexual Distress Scale

Below is a list of feelings and problems that women sometimes have concerning their sexuality.

Please read each item carefully, and click the circle that best describes HOW OFTEN THAT PROBLEM HAS BOTHERED YOU OR CAUSED YOU DISTRESS DURING THE PAST 30 DAYS INCLUDING TODAY.

Click only one number for each item, and take care not to skip any items. If you change your mind, you can change the answer before submit

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Question Title

* 1. How often did you feel ...

	Never	Rarely	Occasionally	Frequently	Always
Distressed about your sex life?	Distressed about your sex life? Never	Distressed about your sex life? Rarely	Distressed about your sex life? Occasionally	Distressed about your sex life? Frequently	Distressed about your sex life? Always
Unhappy about your sexual relationship?	Unhappy about your sexual relationship? Never	Unhappy about your sexual relationship? Rarely	Unhappy about your sexual relationship? Occasionally	Unhappy about your sexual relationship? Frequently	Unhappy about your sexual relationship? Always
Guilty about sexual difficulties?	Guilty about sexual difficulties? Never	Guilty about sexual difficulties? Rarely	Guilty about sexual difficulties? Occasionally	Guilty about sexual difficulties? Frequently	Guilty about sexual difficulties? Always
Frustrated by your sexual problems?	Frustrated by your sexual problems? Never	Frustrated by your sexual problems? Rarely	Frustrated by your sexual problems? Occasionally	Frustrated by your sexual problems? Frequently	Frustrated by your sexual problems? Always
Stressed about sex?	Stressed about sex? Never	Stressed about sex? Rarely	Stressed about sex? Occasionally	Stressed about sex? Frequently	Stressed about sex? Always
Inferior because of sexual problems?	Inferior because of sexual problems? Never	Inferior because of sexual problems? Rarely	Inferior because of sexual problems? Occasionally	Inferior because of sexual problems? Frequently	Inferior because of sexual problems? Always
Worried about sex?	Worried about sex? Never	Worried about sex? Rarely	Worried about sex? Occasionally	Worried about sex? Frequently	Worried about sex? Always
Sexually inadequate?	Sexually inadequate? Never	Sexually inadequate? Rarely	Sexually inadequate? Occasionally	Sexually inadequate? Frequently	Sexually inadequate? Always
Regrets about your sexuality?	Regrets about your sexuality? Never	Regrets about your sexuality? Rarely	Regrets about your sexuality? Occasionally	Regrets about your sexuality? Frequently	Regrets about your sexuality? Always
Embarrassed about sexual problems?	Embarrassed about sexual problems? Never	Embarrassed about sexual problems? Rarely	Embarrassed about sexual problems? Occasionally	Embarrassed about sexual problems? Frequently	Embarrassed about sexual problems? Always
Dissatisfied with your sex life?	Dissatisfied with your sex life? Never	Dissatisfied with your sex life? Rarely	Dissatisfied with your sex life? Occasionally	Dissatisfied with your sex life? Frequently	Dissatisfied with your sex life? Always
Angry about your sex life?	Angry about your sex life? Never	Angry about your sex life? Rarely	Angry about your sex life? Occasionally	Angry about your sex life? Frequently	Angry about your sex life? Always
Bothered by low sexual desire?	Bothered by low sexual desire? Never	Bothered by low sexual desire? Rarely	Bothered by low sexual desire? Occasionally	Bothered by low sexual desire? Frequently	Bothered by low sexual desire? Always

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* 2. What is your month of birth?

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* 3. What day of the month were your born?

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* 4. Your year of birth (written in 4 digits, like 1960 or 2005)

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* 5. Contact info:

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 6. Do you leak urine (even small drops), wet yourself, or wet your pads or undergarments...

	None of the time	Rarely	Once in awhile	Often	Most of the time	All of the time
1. When you cough or sneeze?	1. When you cough or sneeze? None of the time	1. When you cough or sneeze? Rarely	1. When you cough or sneeze? Once in awhile	1. When you cough or sneeze? Often	1. When you cough or sneeze? Most of the time	1. When you cough or sneeze? All of the time
2. When you bend down or lift something up?	2. When you bend down or lift something up? None of the time	2. When you bend down or lift something up? Rarely	2. When you bend down or lift something up? Once in awhile	2. When you bend down or lift something up? Often	2. When you bend down or lift something up? Most of the time	2. When you bend down or lift something up? All of the time
3. When you walk quickly, jog, or exercise?	3. When you walk quickly, jog, or exercise? None of the time	3. When you walk quickly, jog, or exercise? Rarely	3. When you walk quickly, jog, or exercise? Once in awhile	3. When you walk quickly, jog, or exercise? Often	3. When you walk quickly, jog, or exercise? Most of the time	3. When you walk quickly, jog, or exercise? All of the time
4. While you are undressing in order to use the toilet?	4. While you are undressing in order to use the toilet? None of the time	4. While you are undressing in order to use the toilet? Rarely	4. While you are undressing in order to use the toilet? Once in awhile	4. While you are undressing in order to use the toilet? Often	4. While you are undressing in order to use the toilet? Most of the time	4. While you are undressing in order to use the toilet? All of the time
5. Do you get such a strong and uncomfortable need to urinate that you leak urine (even small drops) or wet yourself before reaching the toilet?	5. Do you get such a strong and uncomfortable need to urinate that you leak urine (even small drops) or wet yourself before reaching the toilet? None of the time	5. Do you get such a strong and uncomfortable need to urinate that you leak urine (even small drops) or wet yourself before reaching the toilet? Rarely	5. Do you get such a strong and uncomfortable need to urinate that you leak urine (even small drops) or wet yourself before reaching the toilet? Once in awhile	5. Do you get such a strong and uncomfortable need to urinate that you leak urine (even small drops) or wet yourself before reaching the toilet? Often	5. Do you get such a strong and uncomfortable need to urinate that you leak urine (even small drops) or wet yourself before reaching the toilet? Most of the time	5. Do you get such a strong and uncomfortable need to urinate that you leak urine (even small drops) or wet yourself before reaching the toilet? All of the time
6. Do you have to rush to the bathroom because you get a sudden strong need to urinate?	6. Do you have to rush to the bathroom because you get a sudden strong need to urinate? None of the time	6. Do you have to rush to the bathroom because you get a sudden strong need to urinate? Rarely	6. Do you have to rush to the bathroom because you get a sudden strong need to urinate? Once in awhile	6. Do you have to rush to the bathroom because you get a sudden strong need to urinate? Often	6. Do you have to rush to the bathroom because you get a sudden strong need to urinate? Most of the time	6. Do you have to rush to the bathroom because you get a sudden strong need to urinate? All of the time

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* 7. Are you presently a subject in any clinical research (other than your present application for this study)?

yes

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* 8. If you are in a sexual relationship now, for how many years have you been together?

Less than a year.

More than 1 year.

Not in a sexual relationship.

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* 9. Are you able to travel to Washington DC for 3 study visits in a 12-week period?

yes

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* 10. Have you previously had satisfying orgasms?

yes

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* 11. Have you previously been treated by a physician for problems with orgasm?

yes

Please explain.

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* 12. Please list all prescription medications that you take. If you take no prescriptions medications, just write "none."

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* 13. How many drinks of alcohol to you have per week?

About 1 per week.

About 2 per week.

About 4 per week.

About 7 per week.

More than 7 per week.

More than 14 per week.

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* 14. Are your periods regular?

Yes

It's been more than 12 months since I had a menstrual period.

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Female Sexual Function Index (FSFI)

INSTRUCTIONS: These questions ask about your sexual feelings and responses during the past 4 weeks. Please answer the following questions as honestly and clearly as possible. Your responses will be kept completely confidential. In answering these questions the following definitions apply:

Sexual activity can include caressing, foreplay, masturbation and vaginal intercourse.

Sexual intercourse is defined as penile penetration (entry) of the vagina.

Sexual stimulation includes situations like foreplay with a partner, self-stimulation (masturbation), or sexual fantasy.

CHECK ONLY ONE BOX PER QUESTION

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* 15. Over the past 4 weeks, how often did you feel sexual desire or interest?

Almost always or always

Most times (more that half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

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* 16.
Over the past 4 weeks, how would your rate your level (degree) of sexual desire or interest?

Very high

High

Moderate

Low

Very low or none at all

Sexual arousal is a feeling that includes both physical and mental aspects of sexual excitement. It may include feelings of warmth or tingling in the genitals, lubrication (wetness), or muscle contractions.

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* 17. Over the past 4 weeks, how often did you feel sexually aroused ("turned on") during sexual activity or intercourse?

No sexual activity

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

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* 18. Over the past 4 weeks, how would you rate your level of sexual arousal ("turn on") during sexual activity or intercourse?

No sexual activity

Very high

High

Moderate

Low

Very low or none at all

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* 19. Over the past 4 weeks, how confident were you about becoming sexually aroused during sexual activity or intercourse?

No sexual activity

Very high confidence

High confidence

Moderate confidence

Low confidence

Very low or no confidence

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* 20. Over the past 4 weeks, how often have you been satisfied with your arousal (excitement) during sexual activity or intercourse?

No sexual activity

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

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* 21. Over the past 4 weeks, how often did you become lubricated ("wet") during sexual activity or intercourse?

No sexual activity

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

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* 22. Over the past 4 weeks, how difficult was it to become lubricated ("wet") during sexual activity or intercourse?

No sexual activity

Extremely difficult or impossible

Very difficult

Difficult

Slightly difficult

Not difficult

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* 23. During the past 4 weeks, how often did you maintain your lubrication ("wetness") until completion of sexual activity or intercourse?

No sexual activity

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

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* 24. Over the past 4 weeks, how difficult was it to maintain your lubrication ("wetness") until completion of sexual activity or intercourse?

No sexual activity

Extremely difficult or impossible

Very difficult

Difficult

Slightly difficult

Not difficult

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* 25. Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you reach orgasm (climax)?

No sexual activity

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

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* 26. Over the past 4 weeks, when you had sexual stimulation or intercourse, how difficult was it for you to reach orgasm (climax)?

No sexual activity

Extremely difficult or impossible

Very difficult

Difficult

Slightly difficult

Not difficult

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* 27. Over the past 4 weeks, how satisfied were you with your ability to reach orgasm (climax) during sexual activity or intercourse?

No sexual activity

Very satisfied

Moderately satisfied

About equally satisfied and dissatisfied

Moderately dissatisfied

Very dissatisfied

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* 28. Over the past 4 weeks, how satisfied have you been with the amount of emotional closeness during sexual activity between you and your partner?

No sexual activity

Very satisfied

Moderately satisfied

About equally satisfied and dissatisfied

Moderately dissatisfied

Very dissatisfied

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* 29. Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner?

Very satisfied

Moderately satisfied

About equally satisfied and dissatisfied

Moderately dissatisfied

Very dissatisfied

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* 30. Over the past 4 weeks, how satisfied have you been with your overall sexual life?

Very satisfied

Moderately satisfied

About equally satisfied and dissatisfied

Moderately dissatisfied

Very dissatisfied

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* 31. During the past 4 weeks, how often did you experience discomfort or pain during vaginal penetration?

Did not attempt intercourse

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

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* 32. During the past 4 weeks, how often did you experience discomfort or pain following vaginal penetration?

Did not attempt intercourse

Almost always or always

Most times (more than half the time)

Sometimes (about half the time)

A few times (less than half the time)

Almost never or never

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* 33. Over the past 4 weeks, how would you rate your level (degree) of discomfort or pain during or following vaginal penetration?

Did not attempt intercourse

Very high

High

Moderate

Low

Very low or none at al

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* 34. Your menopausal status

Post Menopausal

Pre Menopausal

I don't know

I've had my ovaries removed.

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100% of survey complete.

Question Title

* 1. How often did you feel ...

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* 2. What is your month of birth?

Question Title

* 3. What day of the month were your born?

Question Title

* 4. Your year of birth (written in 4 digits, like 1960 or 2005)

Question Title

* 5. Contact info:

Question Title

* 6. Do you leak urine (even small drops), wet yourself, or wet your pads or undergarments...

Question Title

* 7. Are you presently a subject in any clinical research (other than your present application for this study)?

Question Title

* 8. If you are in a sexual relationship now, for how many years have you been together?

Question Title

* 9. Are you able to travel to Washington DC for 3 study visits in a 12-week period?

Question Title

* 10. Have you previously had satisfying orgasms?

Question Title

* 11. Have you previously been treated by a physician for problems with orgasm?

Question Title

* 12. Please list all prescription medications that you take. If you take no prescriptions medications, just write "none."

Question Title

* 13. How many drinks of alcohol to you have per week?

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* 14. Are your periods regular?

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* 15. Over the past 4 weeks, how often did you feel sexual desire or interest?

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* 16. Over the past 4 weeks, how would your rate your level (degree) of sexual desire or interest?

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* 17. Over the past 4 weeks, how often did you feel sexually aroused ("turned on") during sexual activity or intercourse?

Question Title

* 18. Over the past 4 weeks, how would you rate your level of sexual arousal ("turn on") during sexual activity or intercourse?

Question Title

* 19. Over the past 4 weeks, how confident were you about becoming sexually aroused during sexual activity or intercourse?

Question Title

* 20. Over the past 4 weeks, how often have you been satisfied with your arousal (excitement) during sexual activity or intercourse?

Question Title

* 21. Over the past 4 weeks, how often did you become lubricated ("wet") during sexual activity or intercourse?

Question Title

* 22. Over the past 4 weeks, how difficult was it to become lubricated ("wet") during sexual activity or intercourse?

Question Title

* 23. During the past 4 weeks, how often did you maintain your lubrication ("wetness") until completion of sexual activity or intercourse?

Question Title

* 24. Over the past 4 weeks, how difficult was it to maintain your lubrication ("wetness") until completion of sexual activity or intercourse?

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* 25. Over the past 4 weeks, when you had sexual stimulation or intercourse, how often did you reach orgasm (climax)?

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* 26. Over the past 4 weeks, when you had sexual stimulation or intercourse, how difficult was it for you to reach orgasm (climax)?

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* 27. Over the past 4 weeks, how satisfied were you with your ability to reach orgasm (climax) during sexual activity or intercourse?

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* 28. Over the past 4 weeks, how satisfied have you been with the amount of emotional closeness during sexual activity between you and your partner?

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* 29. Over the past 4 weeks, how satisfied have you been with your sexual relationship with your partner?

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* 30. Over the past 4 weeks, how satisfied have you been with your overall sexual life?

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* 31. During the past 4 weeks, how often did you experience discomfort or pain during vaginal penetration?

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* 32. During the past 4 weeks, how often did you experience discomfort or pain following vaginal penetration?

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* 33. Over the past 4 weeks, how would you rate your level (degree) of discomfort or pain during or following vaginal penetration?

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* 34. Your menopausal status

* 16.
Over the past 4 weeks, how would your rate your level (degree) of sexual desire or interest?