PRIVATE – FOR DOCTOR ONLY

Questions

Important Note:

THIS INFORMATION IS SEEN BY YOUR DOCTOR ALONE. IT IS TOTALLY SECRET, PRIVATE AND CONFIDENTIAL.

BEST QUESTIONNAIRE SEXUAL DYSFUNCTIONS

Date:

My Name/Nickname:________
Your Phone no.
Your email

Age_________

Marriage
Married Since_______To get married___Just Married___

My marriage is _____ arranged/love/first love than arranged/first arranged than love.
The marriage is forced and against my desire ____yes/no.
I am _____happy/not happy with my husband/wife
For Men

Erection
I have difficulty in getting erection
I have difficulty in maintaining erection
Erection is lost before insertion
Erection is lost at the time of insertion
Erection is lost after insertion
I get erection during masturbation, but at the time of sex my erection becomes less.

Size
Size of my penis is small when in non erect state
Size of my penis is small when in erect state

My foreskin does not go back completely?
I have problem with shape/angle/bend of penis

Early Discharge
I discharge before insertion
I discharge after 1 to 5 strokes
I discharge after 2 minutes

Successive Sex
Sex immediately one after the other.
I wish to do sex __one/two/three more times after first sex
I wish to do sex more than once
Earlier I could do sex ____(2 or 3 specify if more) times one after other. This continued for __months/years after marriage.
Now I wish to do __times sex.

It takes _____time to get erection for second sex.
During the __2nd/3rd subsequent sex erection becomes less.
Discharge is not soon when I do sex 2nd, 3rd time.

Dhat
While straining at stools dhat comes out

Nightfall
I have night fall ____times /month/year

Masturbation
I masturbate ____ times week/month/year.
I stopped masturbation for ________days/months/years.
I have masturbated in excess and at very early age.

For both MEN as well as WOMEN
Frequency of sex
How many times in a week/month
My frequency of sex in last ______months/years is______
I have problem of sex with ________partner other than spouse/spouse/masturbation.
I ____can/cannot do sex well with spouse/partner, but I have difficulty doing sex with
spouse/partner?

Spouse means husband or wife. Partner means girlfriend or boyfriend other than spouse.

When did the problem start?
I have the problem ever since marriage/ even before marriage recently _____months/years.

I believe the my sex problem is because of
1___________

2___________

I think my spouse/partner is not satisfied ____ yes/no.
Actually Spouse/Partner said _____

Sex with partner other than spouse (husband/wife)
Did you have problem with partner 1/ partner 2/ partner 3/? What did partner say?
How many times you had paid sex (prostitute)___
With how many partners you had sex__?
How many times sex with each partner? _____, ____, ____
I had sex before marriage ____ no. of partners ___no. of times
I had sex with some one other than spouse ____ no. of partners ___no. of times with each partner____

What did partner say about the SP Sex Problem

What did friend say

What did doctor say

What remedy have you tried?
List them in detail below
Name of doctor Place Type of Medicine I took treatment for ______days/months
The doctor said SP was because of _____
The improvement was ____% I stopped treatment because ___
I spent money Rs.___
Anything else ________

Insertion
I have pain during sex? ____Yes/No

From the time of marriage I have not been able to do insertion at all.

Am I homosexual?
I believe I have sexual attraction towards same sex people. That is boys having attraction towards boys. Girls having attraction towards girls
I believe I have sexual attraction towards both boys as well as girls.

The difficulties in behavior between husband and wife because of Sexual Problem are ___none/irritability/arguments/fights/other

Sexual Desire
My ____husband/wife has more interest in sex than me. What is the solution?
My desire for sex has become less since ____months____since _____problem started.

Sexual Satisfaction
How can I satisfy my _____husband/wife sexually?
How can both of us have more satisfaction in sex?

My question to the Doctor?
Will my sexual problem be solved?
How much will it cost?
How soon will I get results?
I have questions regarding pregnancy/birth control ____ yes/no.
Are there any medicines and methods that are safe and can increase sexual satisfaction?
I want to know names, functions of sexual parts in men/women.
I want to know facts about what is normal. Example: What is the normal size of penis?

What I want
The improvements in sex that I want are state all
1 _________
2 _________
3 _________

This method of helping to solve sexual problems is very good because _____

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