| 1 | Do you have sexual intercourse more than twice a week? | N | H | O | U | A |
| 2 | Do you find it hard to tell your partner what you like and dislike about your sexual relationship? | N | H | O | U | A |
| 3 | Do you become easily sexually aroused? | N | H | O | U | A |
| 4 | Are you able to delay ejaculation during intercourse if you think you may be "coming" too quickly | N | H | O | U | A |
| 5 | Are you dissatisfied with the amount of variety in your sex life with your partner? | N | H | O | U | A |
| 6 | Do you dislike stroking and caressing your partner’s genitals? | N | H | O | U | A |
| 7 | Do you become tense and anxious when your partner wants to have sex? | N | H | O | U | A |
| 8 | Do you enjoy having sexual intercourse with your partner? | N | H | O | U | A |
| 9 | Do you ask your partner what she likes and dislikes about your sexual relationship? | N | H | O | U | A |
| 10 | Do you fail to get an erection? | N | H | O | U | A |
| 11 | Do you feel there is a lack of love and affection in your sexual relationship with your partner? | N | H | O | U | A |
| 12 | Do you enjoy having your penis stroked and caressed by your partner? | N | H | O | U | A |
| 13 | Can you avoid ejaculating too quickly during intercourse? | N | H | O | U | A |
| 14 | Do you try to avoid having sex with your partner? | N | H | O | U | A |
| 15 | Do you find your sexual relationship with your partner satisfactory? | N | H | O | U | A |
| 16 | Do you get an erection during foreplay with your partner? | N | H | O | U | A |
| 17 | Are there weeks in which you don’t have sex at all? | N | H | O | U | A |