This questionnaire will help start a conversation between you and your doctor. It will help guide the two of you in determining whether you have a condition related to desire, arousal, orgasm or pain.
__ 1. I am not satisfied with my sex life.
__ 2. I would like my sex life to be better.
__ 3. I have noticed a recent change related to my sex life.
__ 4. My sexual concerns cause me personal distress.
__ 5. My interest in sex has decreased.
__ 6. I do not have erotic thoughts or fantasies.
__ 7. I have no interest in having any kind of sexual activity.
__ 8. I have vaginal dryness during sex.
__ 9. I have less pleasurable sensation, such as warmth and tingling, during sex.
__ 10. I do not feel excited or aroused during sex.
__ 11. I have pain during sexual intercourse.
__ 12. My vagina tightens up during sex and is difficult to enter.
__ 13. I have pain with any kind of vaginal penetration.
__ 14. I have pain during sexual intercourse, but I think I have enough lubrication or wetness.
__ 15. I do not have orgasms.
__ 16. It is more difficult for me to have an orgasm that it once was.
__ 17. I find my orgasms are less intense than they once were.
__ 18. I have sexual difficulties when I have sex with my partner but not when I self-stimulate alone.
__ 19. I think I suffer from depression.
__ 20. I think my sexual problems are psychological.
__ 21. I am not happy with my partner.
__ 22. My sexual problems began after an illness, injury or surgery.
__ 23. My sexual problems began at about the same time as: (Check all that apply)
__ birth control
__ hormonal replacement therapy
24. I have one or more of the following: (Check all that apply)
__ heart disease
__ high cholesterol
__ pelvic surgery, such as hysterectomy
__ pelvic radiation therapy
__ smoking or history of smoking
__ 25. I think my sexual problems are physical.
This quiz was developed by Dr. Kevin Billups, a board-certified urologist specializing in male and female sexual health; Dr. Phillip Sarrell, a board-certified gynecologist specializing in menopause and aging issues; and Dr. MaryAnn Schroder, a board-certified clinical sexologist and certified family nurse practitioner specializing in women’s sexual health.
Eros Therapy is not right for everyone, but may be an appropriate treatment if you have a condition related to problems with arousal or orgasm.
Phone: 1-877-774-1442 (answered by Curt or Erika)