This index covers material that is sensitive and personal. Your responses will be kept completelv confidential. If von are unable or do not wish lo answer anv question, vou mav leave it blank. Answer the Iollowing questions by choosing the most accurate response for the past month.
1. Do you currently have a sex partner? Yes No
2. Have you been sexually active during the past monlh? Yes No
3. During the past month, how Irequently have you had sexual thoughts, Iantasies, or erotic dreams? (Picase circle the most appropriate response.) 0) Not at all 1) Once 2) 2 or 3 times 3) Once a week 4) 2 or 3 times per weck 5) Once a day 6) More ihan once a day 4. Using the scale to the right, indicate how Irequently you have Ielt a desire to engage in the Iollowing activities during the past month? (An answer is required for each, even if it mav nol applv to vou.) Kissing ........ 0) Not at all Masturbation alone ........ 1) Once Mutual masturbation ........ 2) 2 or 3 times Petting and Ioreplay ........ 3) Once a week Oral sex ........ 4) 2 or 3 times per week Vaginal penetralion or intercourse ........ 5) Once a day Anal sex ........ 6) More than once a day
5. Using the scale to the right, indicate how Irequently you have become aroused by the Iollowing sexual experienccs during the past month. (An answer is required for each, even if it mav nol applv to vou.) Kissing ........ 0) Have not engaged in this activity Dreams or Iantasy ......... 1) Not at all MasiVbation alone ........ 2) Seldom, less than 25 oI the time Mutual masturbation ........ 3) Sometimes, about 50 oI the time Petting and Ioreplay ........ 4) Usually, about 75 oI the time Oral sex ......... 5) Always became aroused Vaginal penetration or intercourse ........ Anal sex ........
6. Overall, during the past month, how Irequently have you become anxious or inhibited during sexual activity with a partner? (Picase circle the most appropriate response.) 0) I have not had a partner 1) Not at all anxious or inhibited 2) Seldom, less than 25 oI the time 3) Sometimes, about 50 oI the time 4) Usually, about 75 oI the time 5) Always became anxious or inhibited
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7. Using the scale to the right, indicate how Irequently you have engaged in the Iollowing sexual experiences during the past month? (An answer is required for each, even if it mav not applv to vou.) Kissing ........ 0) Not at all Sexual Iantasy ........ 1) Once Masturbation alone ........ 2) 2 or 3 times Mutual masturbation ........ 3) Once a week Petting and Ioreplay ........ 4) 2 or 3 times per week Oral sex ........ 5) Once a day Vaginal penetralion or intercourse ........ 6) More than once a day Anal sex ........ 8. During the past month, who has usually initiated sexual activity? (Picase circle the most appropriate response.) 0) I have not had a partner 1) I have not had sex with a partner during Ihe past month 2) I usually have initiated activity 3) My parlner and I have equally initiated activity 4) My partner usually has initiated activity. 9. During the past month, how havc you usually responded lo your partner's sexual advances? (Picase circle the most appropriate response.) 0) I have not had a partner 1) Has not happcned during the past month 2) Usually reIused 3) Somelimes reIused 4) Accepled reluctantly 5) Accepted, but not necessarily with pleasure 6) Usually accepted with pleasure 7) Always accepted with pleasure 10. During the past month, have you Ielt pleasure Irom any Iorms oI sexual experience? (Picase circle Ihe most appropriate response.) 0) I have not had a partner 1) Have had no sexual experience during the past month 2) Have not Ielt any pleasure 3) Seldom, less than 25 oI the time 4) Sometimes, about 50 oI the time 5) Usually, about 75 oI the time 6) Always Ielt pleasure
11. Using the scale to the right, indicate how oIten you have reached orgasm during the past month with the Iollowing activities. (An answer is required for each, even if it mav not applv lo vou.) In dreams or Iantasy ........ 0) I have not had a partner Kissing ......... 1) Have not engaged in this activity Masturbation alone ........ 2) Not at all Mutual masturbation ........ 3) Seldom, less than 25 oI the time Petting and Ioreplay ........ 4) Sometimes, about 50 oI the time Oral sex ........ 5) Usually about 75 oI the time Vaginal penelration or intercourse ........ 6) Always reached orgasm Anal sex ........
12. During the past month, has Ihe Irequcncy oI your sexual aclivity with a partner been: (Please circle the most appropriale response.) 0) I have not had a partner 1) Less than you desired 2) As much as you desired 3) More than you desired
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13. Using the scale to the right, indicate Ihe level oI change, iI any, in the Iollowing areas during the past monlh? (An answer is required for each, even if it mav not applv to vou.) Sexual interest ......... 0) Not applicable Sexual arousal ......... 1) Much lower level Sexual activity ......... 2) Somewhat lower level Sexual satisIaction ......... 3) No change Sexual anxiety ......... 4) Somewhat higher level ......... 5) Much higher level
14. During the past month, how Irequently have you expcrienced Ihe Iollowing? (An answer is required for each, even if il mav not applv to vou)
Bleeding or irritation aIter vaginal penetration ....... 0) Not at all or intercourse ........ 1)Seldom, less than 25 oI the time Lack oI vaginal lubrication . ....... 2)Sometimes, about 50 oI the time PainIul penetration or intercourse ....... 3) Usually, about 75 oI the time DiIIiculty reaching orgasm ....... 4) Always Vaginal tightness ...... Involuntary urination ........ Headaches aIter sexual activity ........ Vaginal inIection ........
15. Using the scale to the right, indicate Ihe Irequency with which the Iollowing Iactors have inIluenced your level oI sexual activity during the past month. (An answer is re- quired for each, even if it mav not applv to vou.) My own health problems ........ 0) I have not had a partner (Ior example, inIection, illness) ........ 1) Not at all My partner's health problems ........ 2) Seldom, less than 25 oI the time ConIlict in the relationship ......... 3) Sometimes, about 50 oI the time Lack oI privacy ......... 4) Usually, about 75 oI the time Other (picase speciIy): ......... 5) Always ......................................... 16. How satisIied are you with Ihe overall appearance oI your body? (Please circle the most appropriale response.) 0) Very satisIied 1) Somewhat satisIied 2) Neither satisIied nor dissatisIied 3) Somewhat dissatisIied 4) Very dissatisIied
17. During the past month, how Irequently have you been able to communicate your sexual desires or preIerences to your partner? (Please circle the most appropriale response.) 0) I have not had a partner 1) I have been unable to communicate my desires or preIerences 2) Seldom, about 25 oI the time 3) Sometimes, about 50 oI the time 4) Usually, about 75 oI the time 5) I was always able lo communicate my desires or preIerences
18. Overall, how satisIied have you been with your sexual relationship with your partner? (Please circle the most appropriate response.) 0) I have not had a partner 1) Very salisIied 2) Somewhat satisIied 3) Neither satisIicd nor dissatisIied 4) Somewhat dissalisIied 5) Very dissatisIied
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19. Overall, how satisIied do you think your partner has bccn with your sexual relation ship? (Please circle the most appropriate response.) 0) I have not had a partner 1) Very salisIied 2) Somewhat satisIied 3) Neither salisIied or dissatisIied 4) Somewhat dissatisIied 5) Very dissatisIied 20. Overall, how importan! a part oI your liIe is your sexual activity? (Please circle the most appropriate response.) 0) Not at all important 1) Somewhat unimportant 2) Neither important nor unimportant 3) Somewhat important 4) Very important 21. Circle the number that corresponds to the statement that best describes your sexual experience. 1) Entirely heterosexual 2) Largely heterosexual, but some homosexual experience 3) Largely heterosexual, but considerable homosexual experience 4) Equally heterosexual and homosexual 5) Largely homosexual, but considerable heterosexual experience
22. Circle the number that corresponds to the statement Ihat best describes your sexual desires. 1) Entirely heterosexual 2) Largely heterosexual, but some homosexual dcsire 3) Largely heterosexual, but considerable homosexual desire 4) Equally heterosexual and homosexual 5) Largely homosexual, but considerable heterosexual desire 6) Largely homosexual, but some heterosexual desire 7) Entirely homosexual