Questionnaire

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1. Overall, I am satisfied with how my body looks.

Strongly Disagree					Strongly Agree		NA
1	2	3	4	5	6	7	0

2. My current or last partner is/was satisfied with how my body looks.

Strongly Disagree					Strongly Agree		NA
1	2	3	4	5	6	7	0

3. My feelings about my body interfere with my sexual satisfaction.

Strongly Disagree					Strongly Agree		NA
1	2	3	4	5	6	7	0

4 a. My weight is ________ pounds.

b. My height is __ feet__ inches.

5 a. I have had the following surgery.

(Please check those you have had and write in your age at the time of the surgery):

	Age at time of surgery
Hysterectomy (uterus removed)
Ovaries removed
Mastectomy
Other surgery (please specify)
b. I have the following physical condition(s)
Please mark and indicate your age when the condition began. Age of onset
Diabetes
Chronic vaginal dryness (currently)
Chronic bladder infections (currently)
Other illness, disability, or physical condition (please specify)
None
6. In the past year I have taken the following medications or hormones
Please mark and indicate the number of years taken.	No. of Years Taken
Blood pressure medication
Antihistamine
Antidepressant
Antianxiety medication
Insulin
Birth control pills
Other estrogen
Other progestin/progesterone
Other medications or hormones (Please specify)
None

7. The physical condition of my body interferes with my sexual satisfaction.

Strongly Disagree					Strongly Agree		NA
1	2	3	4	5	6	7	0

Answer Question 8 only if you are not now physically able to become pregnant. Give ages for all you have experienced:

8. I am not physically able to become pregnant because (give ages for all that apply):

I reached menopause at age________.

I had my tubes tied when I was age _________.

I had a hysterectomy when I was age____________.

I had/have had endometriosis from approximately age________.

I had a pelvic infection when I was age________.

Other (please specify):_______________.

Remember

The questionnaire is here for VIEWING ONLY.
Please DO Not send your answers to me.