Low Sex Drive Questionnaire

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Step 1 of 4

25%

1. In the past was your level of sexual desire or interest good and satisfy to you*

Yes

No

2. has there been a decrease in your level of sexual desire or interest*

Yes

No

3. Are you bothered by your decreased level of sexual desire or interest?*

Yes

No

4. Would you like your level of sexual desire or interest to increase?*

Yes

No

5. Please check all the factors that you feel may be contributing to your current decrease in sexual desire or interest:*

An operation, depression, injuries, or other medical condition

Medication, drugs, or alcohol you are currently taking

Pregnancy, recent childbirth, menopausal symptoms

Other sexual issues you may be having (pain, decreased arousal or orgasm)

Your partner’s sexual problems

Dissatisfaction with your relationship or partner

Stress or fatigue

None of the Above

Other

Name*

First Last

Email*

Phone*

Date of Birth*

MM slash DD slash YYYY

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