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What is your marital status?
 
Single
 
Married
 
Divorced
 
Widowed
 
 
How satisfied are you in the following aspects of your relationship
Very Unsatisfied Unsatisfied Neutral Satisfied Very Satisfied
Communication
Emotional Support
Intimacy
 
 
 
Have you ever been unfaithful to your current partner?
 
Yes
 
No
 
Thought About It
 
 
 
What turns you on?
   
 
 
 
What do you find attractive in the opposite sex (check all that apply)?
 
Nice Body
 
Sense of Humor
 
Smile
 
Well Groomed
 
Intelligence
 
Sense of Family
 
Personality
 
Popularity

 
 
The last time I felt turned on by ______ was _______?
Less than 1 month ago Less than 6 months ago Less than 1 year ago More than 1 year ago Never
My Partner
Something I Read
Something I Watched
 
 
 
To me, an intimate evening looks like:
   
 
 
How Often Do You...
Very Frequently Occasionally Rarely Never I've tried it but didn't like it
Pleasure yourself
Explore your body
 
 
 
How adventurous do you want to be in the bedroom?
 
Very
 
Somewhat
 
Not At All
 
 
 
How often do you think about intimate things?
 
Multiple Times a Day
 
Daily
 
Every Now and Then
 
Rarely
 
Never
 
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