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Dr. Jacquelyn Paykel
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Sexual Health
1. Over the past 4 weeks, how often did you feel sexual desire or interest?

5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never

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

5 = Very high
4 = High
3 = Moderate
2 = Low
1 = Very low or none at all

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

0 = No sexual activity
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never

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

0 = No sexual activity
5 = Very high
4 = High
3 = Moderate
2 = Low
1 = Very low or none at all

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

0 = No sexual activity
5 = Very high confidence
4 = High confidence
3 = Moderate confidence
2 = Low confidence
1 = Very low or no confidence

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

0 = No sexual activity
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never

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

0 = No sexual activity
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never

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

0 = No sexual activity
1 = Extremely difficult or impossible
2 = Very difficult
3 = Difficult
4 = Slightly difficult
5 = Not difficult

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

0 = No sexual activity
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never

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

0 = No sexual activity
1 = Extremely difficult or impossible
2 = Very difficult
3 = Difficult
4 = Slightly difficult
5 = Not difficult

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

0 = No sexual activity
5 = Almost always or always
4 = Most times (more than half the time)
3 = Sometimes (about half the time)
2 = A few times (less than half the time)
1 = Almost never or never

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

0 = No sexual activity
1 = Extremely difficult or impossible
2 = Very difficult
3 = Difficult
4 = Slightly difficult
5 = Not difficult

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

0 = No sexual activity
5 = Very satisfied
4 = Moderately satisfied
3 = About equally satisfied and dissatisfied
2 = Moderately dissatisfied
1 = Very dissatisfied

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

0 = No sexual activity
5 = Very satisfied
4 = Moderately satisfied
3 = About equally satisfied and dissatisfied
2 = Moderately dissatisfied
1 = Very dissatisfied

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

5 = Very satisfied
4 = Moderately satisfied
3 = About equally satisfied and dissatisfied
2 = Moderately dissatisfied
1 = Very dissatisfied

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

5 = Very satisfied
4 = Moderately satisfied
3 = About equally satisfied and dissatisfied
2 = Moderately dissatisfied
1 = Very dissatisfied

17. Over the past 4 weeks, how often did you experience discomfort or pain during vaginal
penetration?

0 = Did not attempt intercourse
1 = Almost always or always
2 = Most times (more than half the time)
3 = Sometimes (about half the time)
4 = A few times (less than half the time)
5 = Almost never or never

18. Over the past 4 weeks, how often did you experience discomfort or pain following vaginal
penetration?

0 = Did not attempt intercourse
1 = Almost always or always
2 = Most times (more than half the time)
3 = Sometimes (about half the time)
4 = A few times (less than half the time)
5 = Almost never or never

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

0 = Did not attempt intercourse
1 = Very high
2 = High
3 = Moderate
4 = Low
5 = Very low or none at all
weeks. Please answer the following questions as honestly and clearly as possible.

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.

PICK ONLY ONE ANSWER PER QUESTION.
Sexual desire or interest is a feeling that includes wanting to have a sexual experience, feeling
receptive to a partner's sexual initiation, and thinking or fantasizing about having sex.

Add the result of questions 1, 2 then multiply by 0.6 =  ________

Add the result of questions 3-6 then multiply by 0.3 =  _______

Add the result of questions 7-10 then multiply by 0.3 =  ________

Add the result of questions 11-13 then multiply by 0.4 =  ________

Add the result of questions 14-16 then multiply by 0.4 =  ________

Add the results of questions 17-19 then multiply by 0.4 =  ________

Now add the score from each line  ________

If your total score is:
0-26.4 this is considered "normal" for research purposes, however you still may benefit from a visit
with a sexual health specialist;
> 26.5 indicates likely sexual dysfunction and you would likely
benefit from a visit with a sexual health specialist.