Date of Examination

Patient Number

Patient Initials

Month

Day

Year

 

 

 

First

Mid

Last

 

 

 

 

 

 

 

 

 

Video Assessment Questionnaire

 

1. How relaxed did you feel during this video presentation?

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

…………………………….…………...…..0…1…2…3…4… 5…6…7…8…9…10

 

2. How much did you enjoy watching the video?

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

…………………………….…………...…..0…1…2…3…4… 5…6…7…8…9…10

 

  1. How much subjective arousal did you have during this video?

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

    …………………………….…………...…..0…1…2…3…4… 5…6…7…8…9…10

     

  2. How much lubrication (wetness) did you feel during this video?

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

    …………………………….…………...…..0…1…2…3…4… 5…6…7…8…9…10

     

  3. How much engorgement (fullness) did you feel during this video?

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

    …………………………….…………...…..0…1…2…3…4… 5…6…7…8…9…10

     

  4. How much tingling or fullness in your genitals did you feel while watching this video?

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

    …………………………….…………...…..0…1…2…3…4… 5…6…7…8…9…10

     

  5. Did you notice any other physical reactions while taking the medication?

    6.  

  6. Did you notice any other psychological reactions while taking the medication?

    7.  

  7. Based upon the reactions you experienced in the laboratory, would you consider using

this medication in a real-life situation?

 

a. definitely b. possibly c. probably not d. definitely not

.