Version May 2024
| INSTRUCTIONS: These questions ask about your sex life over the past four weeks. Please answer the following questions as honestly and clearly as possible. In answering these questions, the following definitions apply: |
|
| Check ONLY one box per question. |
| 1. Over the past four weeks, how often were you able to get an erection during sexual activity? |
| 0 = No sexual activity |
| 1 = Almost never or never |
| 2 = A few times (much less than half the time) |
| 3 = Sometimes (about half the time) |
| 4 = Most times (much more than half the time) |
| 5 = Almost always or always |
| 2. Over the past four weeks, when you had erections with sexual stimulation, how often were your erections hard enough for penetration? |
| 0 = No sexual activity |
| 1 = Almost never or never |
| 2 = A few times (much less than half the time) |
| 3 = Sometimes (about half the time) |
| 4 = Most times (much more than half the time) |
| 5 = Almost always or always |
| The next eight questions will ask about the erections you may have had during sexual intercourse. |
| 3. Over the past four weeks, when you attempted sexual intercourse, how often were you able to penetrate (enter) your partner? |
| 0 = Did not attempt intercourse |
| 1 = Almost never or never |
| 2 = A few times (much less than half the time) |
| 3 = Sometimes (about half the time) |
| 4 = Most times (much more than half the time) |
| 5 = Almost always or always |
| 4. Over the past four weeks, during sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? |
| 0 = Did not attempt intercourse |
| 1 = Almost never or never |
| 2 = A few times (much less than half the time) |
| 3 = Sometimes (about half the time) |
| 4 = Most times (much more than half the time) |
| 5 = Almost always or always |
| 5. Over the past four weeks, during sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? |
| 0 = Did not attempt intercourse |
| 1 = Extremely difficult |
| 2 = Very difficult |
| 3 = Difficult |
| 4 = Slightly difficult |
| 5 = Not difficult |
| 6. Over the past four weeks, how many times have you attempted sexual intercourse? |
| 0 = No attempts |
| 1 = One to two attempts |
| 2 = Three to four attempts |
| 3 = Five to six attempts |
| 4 = 7 to 10 attempts |
| 5 = 11 or more attempts |
| 7. Over the past four weeks, when you attempted sexual intercourse, how often was it satisfactory for you? |
| 0 = Did not attempt intercourse |
| 1 = Almost never or never |
| 2 = A few times (much less than half the time) |
| 3 = Sometimes (about half the time) |
| 4 = Most times (much more than half the time) |
| 5 = Almost always or always |
| 8. Over the past four weeks, when you attempted sexual intercourse, how much have you enjoyed sexual intercourse? |
| 0 = No intercourse |
| 1 = No enjoyment |
| 2 = Not very enjoyable |
| 3 = Fairly enjoyable |
| 4 = Highly enjoyable |
| 5 = Very highly enjoyable |
| 9. Over the past four weeks, when you had sexual stimulation or intercourse, how often did you ejaculate? |
| 0 = No sexual stimulation/intercourse |
| 1 = Almost never or never |
| 2 = A few times (much less than half the time) |
| 3 = Sometimes (about half the time) |
| 4 = Most times (much more than half the time) |
| 5 = Almost always or always |
| 10. Over the past four weeks, when you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax? |
| 0 = No sexual stimulation/intercourse |
| 1 = Almost never or never |
| 2 = A few times (much less than half the time) |
| 3 = Sometimes (about half the time) |
| 4 = Most times (much more than half the time) |
| 5 = Almost always or always |
| The next five questions ask about sexual desire. Let's define sexual desire as a feeling that may include wanting to have a sexual experience (for example, masturbation or intercourse), thinking about having sex, or feeling frustrated due to lack of sex. |
| 11. Over the past four weeks, how often have you felt sexual desire? |
| 1 = Almost never or never |
| 2 = A few times (much less than half the time) |
| 3 = Sometimes (about half the time) |
| 4 = Most times (much more than half the time) |
| 5 = Almost always or always |
| 12. Over the past four weeks, how would you rate your level of sexual desire? |
| 1 = Very low or not at all |
| 2 = Low |
| 3 = Moderate |
| 4 = High |
| 5 = Very high |
| 13. Over the past four weeks, how satisfied have you been with your overall sex life? |
| 1 = Very dissatisfied |
| 2 = Moderately dissatisfied |
| 3 = About equally satisfied and dissatisfied |
| 4 = Moderately satisfied |
| 5 = Very satisfied |
| 14. Over the past four weeks, how satisfied have you been with your sexual relationship with your partner? |
| 1 = Very dissatisfied |
| 2 = Moderately dissatisfied |
| 3 = About equally satisfied and dissatisfied |
| 4 = Moderately satisfied |
| 5 = Very satisfied |
| 15. Over the past four weeks, how do you rate your confidence that you can get and keep an erection? |
| 1 = Very low |
| 2 = Low |
| 3 = Moderate |
| 4 = High |
| 5 = Very high |
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