Sexual Performance Self-Report Questionnaire Form
Please complete this brief, anonymous self-report questionnaire to help reflect on your experiences. All questions are optional and phrased in a neutral, clinical manner.
Age Range
Please Select
18–24
25–34
35–44
45–54
55–64
65 or older
Prefer not to say
Relationship Status
Single
In a relationship
Married or partnered
Divorced or separated
Widowed
Other
How often do you engage in sexual activity?
Several times a week
About once a week
A few times a month
Rarely
Not at all
Current Level of Satisfaction with Sexual Performance
Very satisfied
Somewhat satisfied
Neutral
Somewhat dissatisfied
Very dissatisfied
Common Areas of Concern (select all that apply)
Desire or interest
Arousal
Orgasm
Physical comfort
Performance anxiety
None
Other
Are your concerns occasional or persistent?
Occasional
Persistent
Not applicable
Main Context When Concerns Appear
With a partner
Alone
Both
Not applicable
Duration of Concern
Please Select
Less than 1 month
1–6 months
6–12 months
More than a year
Not applicable
Have you discussed these concerns with a healthcare or mental health professional?
Yes
No
Additional Notes (optional)
Submit
Should be Empty: