Female Sexual Health Index Form | Dr Natalia Novikova

Patient's Name *

Age *

Date of Birth

Marital Status

Are you completing this form:

Pre-treatment

Post-treatment

If post-treatment please specify treatment(s)

INSTRUCTIONS: The below questions ask about your sexual feelings and responses during the past four weeks. Please answer as honestly and clearly as possible. Your responses will be kept completely confidential.

In answering these questions the following definitions apply:

ONLY ONE OPTION PER QUESTION MAY BE SELECTED. ALL QUESTIONS RELATE TO YOUR EXPERIENCES DURING THE PAST FOUR WEEKS.

1. How often did you feel sexual desire/interest? *

Almost never (0)

Not very often (1)

Often (2)

Most of the time (3)

Almost always/Always (4)

2. How would you rate your level (degree) of sexual desire/interest? *

3. How often were you sexually aroused (turned on) during sexual activity or intercourse? *

No sexual activity (0)

Almost never/never (1)

Not very often (2)

Often (3)

Most of the time (4)

Almost always/Always (5)

4. How would you rate your sexual arousal during sexual activity or intercourse? *

5. How would you rate your confidence about becoming sexually aroused during sexual activity or intercourse? *

6. How satisfied have you been with your sexual arousal level (excitement) during sexual activity or intercourse? *

No sexual activity (0)

Almost never/Never (1)

Not very often (2)

Often (3)

Most of the time (4)

Almost always/Always (5)

7. How often did you become lubricated (wet) during intercourse? *

No sexual activity (0)

Almost never/Never (1)

Not very often (2)

Often (3)

Most of the time (4)

Almost always/Always (5)

8. How difficult was it to become lubricated (wet) during sexual activity or intercourse? *

No sexual activity (0)

Extremely/Impossible (1)

Very difficult (2)

Difficult (3)

Slightly difficult (4)

Not difficult (5)

9. How often did you maintain your lubrication (wetness) until completion of sexual activity or intercourse? *

No sexual activity (0)

Almost never/Never (1)

Not very often (2)

Often (3)

Most of the time (4)

Almost always/Always (5)

10. How difficult was it to maintain your lubrication (wetness) until completion of sexual activity or intercourse? *

No sexual activity (0)

Extremely/Impossible (1)

Very difficult (2)

Difficult (3)

Slightly difficult (4)

Not difficult (5)

11. When you had sexual stimulation or intercourse, how often did you reach orgasm (climax)? *

No sexual activity (0)

Almost never/never (1)

Not very often (2)

Often (3)

Most of the time (4)

Almost always/Always (5)

12. When you had sexual stimulation or intercourse, how difficult was it for you to reach orgasm (climax)? *

No sexual activity (0)

Extremely/Impossible (1)

Very difficult (2)

Difficult (3)

Slightly difficult (4)

Not difficult

13. How satisfied were you with your ability to reach orgasm (climax)? *

No sexual activity (0)

Very dissatisfied (1)

Moderately dissatisfied (2)

Equally dissatisfied and satisfied (3)

Moderately satisfied (4)

Very satisfied (5)

14. How satisifed have you been with the amount of emotional closeness between you and your partner during sexual activity of intercourse? *

Not sexual activity (0)

Very dissatisfied (1)

Moderately dissatisfied (2)

Equally dissatisfied and satisfied (3)

Moderately satisfied (4)

Very satisfied (5)

15. How satisfied have you been with your sexual relationship with your partner? *

No sexual activity (0)

Very dissatisfied (1)

Moderately dissatisfied (2)

Equally dissatisfied and satisfied (3)

Moderately satisfied (4)

Very satisfied (5)

16. How satisfied have you been with your sexual life? *

No sexual activity (0)

Very dissatisfied (1)

Moderately dissatisfied (2)

Equally dissatisfied and satisfied (3)

Moderately satisfied (4)

Very satisfied (5)

New Option

17. How often did you experience discomfort or pain during vaginal penetration? *

No sexual activity (0)

Almost always/Always (1)

Most of the time (2)

Often (3)

Not very often (4)

Almost never/Never (5)

18. How often did you experience discomfort or pain following vaginal penetration? *

No sexual activity (0)

Almost always/ Always (1)

Most of the time (2)

Often (3)

Not very often (4)

Almost never/Never (5)

19. How would you rate your level (degree) of discomfort or pain following vaginal penetration? *

Please list any other sexual problems that you may experience below?

THANK YOU FOR COMPLETING THIS QUESTIONNAIRE