Pornography Use Self-Assessment Questionnaire
A neutral self-assessment form about the user’s viewing patterns, frequency, triggers, and perceived impact. The form title must remain exactly "Pornography Use Self-Assessment Questionnaire" throughout.
Assessment Details
Preferred display name or alias
Assessment timeframe
*
Past 7 days
Past 30 days
Past 3 months
Longer than 3 months
Overall response style
*
Mostly yes
Somewhat yes
Mixed
Mostly no
Use Pattern Frequency
How often does this behavior occur?
*
Rarely
1
2
3
4
Very often
5
1 is Rarely, 5 is Very often
Please indicate how often each statement applies to you
*
Rows
Never
Rarely
Sometimes
Often
Very often
I think about it more than I intend to.
1
2
3
4
5
I spend more time than planned.
6
7
8
9
10
It is hard to stop once I start.
11
12
13
14
15
Usual time of day
*
Morning
Afternoon
Evening
Late night
Varies
Impact and Context
Impact in the following areas
*
Rows
1
2
3
4
5
Concentration
16
17
18
19
20
Sleep routine
21
22
23
24
25
Productivity
26
27
28
29
30
Mood
31
32
33
34
35
Main trigger or context
*
Stress
Boredom
Loneliness
Habit
Curiosity
Other
Brief notes (optional)
How concerning does this pattern feel to you?
*
Not concerning
1
2
3
4
Very concerning
5
1 is Not concerning, 5 is Very concerning
Submit
Should be Empty: