Visit X

Date of Examination

Rand/Patient Number

Patient Initials

 

 

 

 

 

 

 

 

 

 

Video Assessment Questionnaire

Please answer the following questions in regard to the erotic video that you have just seen. Please circle the number that best describes your response on a scale from 0 to 10, with 0 meaning "not at all" and 10 meaning "very much."

 

…………………………………………….Not at all……………………………….Very much

1. How pleasurable did you find the…………..0…1…2…3…4… 5…6…7…8…9…10

vibrator and video stimulation?

 

…………………………………………….Not at all……………………………….Very much

2. How much subjective arousal did you………0…1…2…3…4… 5…6…7…8…9…10

have during the stimulation?

…………………………………………….Not at all……………………………….Very much

3. How firm was your erection during………..0…1…2…3…4… 5…6…7…8…9…10

the stimulation?

 

…………………………………………….Not at all……………………………….Very much

4. How relaxed did you feel during the……….0…1…2…3…4… 5…6…7…8…9…10

stimulation?

 

5. Did you have any discomfort during the vibrator stimulation? Please specify:

 

6. Did you ejaculate (reach climax) during the video and vibrator portion of the session?

A. yes

B. no