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Brief Sexual Symptom Checklist

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The following questionnaire is based on a checklist developed for doctors to use in their office. It appeared in an issue of the Journal of Sexual Medicine.

The results cannot be verified.

Please answer the following questions about your overall sexual function in the past 3 months or more.

Are you satisfied with your sexual function? [Select One]
Yes
No
How long have you been dissatisfied with your sexual function? [Select One]
1 month
3 months
6 months
1 year
2 years
3 years
4 years
5 years
More than 5 years
I am satisfied with my sexual function
The problem(s) with your sexual function is: [Select All That Apply]
1 Problems with little or no interest in sex
2 Problems with decreased genital sensation (feeling)
3 Problems with decreased vaginal lubrication (dryness)
4 Problems reaching orgasm
5 Problems with pain during sex
6 Other
I am satisfied with my sexual function
Which problem is most bothersome? [Select One]
1
2
3
4
5
6
I am satisfied with my sexual function
If given the opportunity would you like to talk to your doctor about this? [Select One]
Yes
No
I am satisfied with my sexual function
Would you like to see your doctor(s) use this type of checklist during your visits? [Select One]
Yes
No
Maybe
They already do
This poll was created on 2005-06-05 23:48:33 by The-Clitoris.com