Visit X
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Date of Examination |
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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