BIENESTAR SEXUAL FUNCTION ASSESMENT™ 

(EVALUACION DE SU FUNCION SEXUAL)

SEXUAL FUNCTION QUESTIONNAIRE (PREGUNTAS)(PART A)

BACKGROUND QUESTIONS(Circle/Circule)

Have you ever been evaluated or received any treatment for a sexual problem?  No / Yes (Si)

(Ha sido evaluado o recibido algún tratamiento para un problema sexual)

Ø  During the past week, how often have you found yourself thinking about sex with any interest or desire?(Durante la semana pasada, cuantas veces se ha encontrado usted pensando en sexo con mucho interés)

 I = Several times a day (Algunas veces)

2 = At least once a day (1 vez al día)

3 = At least twice a week (2 vez por semana)

4 = At least once a week (1 vez por semana)

5 = Not at all (Nunca)

Ø  Were you sexually active during the past week? (Usted ha sido activo sexualmente la semana pasada) No / Yes

*If 'YES', please complete the remainder of this questionnaire

(Al responder (SI/YES) complete el restante de las preguntas)

During the past week:

(Durante la semana pasada)

Ø  How would you describe your ability to enjoy sex? (Como describe si habilidad para disfrutar el sexo)

 I = Fully enjoyed (Disfruto siempre)

2 = Sometimes enjoyed (Algunas veces disfruto)

3 = Barely enjoyed (Casi nunca)

4 = Never enjoyed (Nunca)

Ø  Overall, how satisfied were you with your sexual functioning? (En su totalidad que tan satisfecho está usted con su función sexual)

1 = Completely (Completamente)

2 = Highly (Mucho)

3 = Moderately (Moderadamente)

4 = Slightly (Poco instantes)

5 = Not at all (Nunca)

BIENESTAR SEXUAL FUNCTION QUESTIONNAIRE(PART B)

Please read each question below and circle the ONE number that best describes your feelings

(Leer cada pregunta y circule el número que más le describe sus sentimientos)

FOR WOMEN ONLY:

(PARA MUJERES SOLAMENTE)

*During the past week: (Durante la semana pasada)

Ø  How often have you become sexually aroused (sexually excited)? (Que tan frecuente se excita usted sexualmente)

1 = Often (Frecuentemente)

2 = Sometimes (Algunas veces)

3 = Rarely (Casi nunca)

4 = Never (Nunca)

Ø  How easily have you become sexually aroused or sexually excited (Que tan fácilmente se excita usted sexualmente)

1 = Very easily (Fácilmente)

2 = Sometimes easily (Algunas veces)

3 = Rarely easily (Casi Nunca)

4 = Never easily (Nunca)

Ø  Have you had adequate vaginal lubrication during sexual activity? (Tiene usted lubricación vaginal durante el acto sexual)

1 = Very easily (Fácilmente)

2 = Sometimes easily (Algunas veces)

3 = Rarely easily (Casi Nunca)

4 = Never easily (Nunca)

Ø  How often did you have difficulty achieving orgasm? (Que tan difícil se le hace a usted tener un orgasmo)

1 = Very easily (Facilmente)

2 = Sometimes easily (Algunas veces)

3 = Rarely easily (Casi Nunca)

4 = Never easily (Nunca)

Ø  How often were you unable to reach orgasm? (Que frecuentemente se le hace difícil llegar a tener un orgasmo)

1 = Very easily (Fácilmente)

2 = Sometimes easily (Algunas veces)

3 = Rarely easily (Casi Nunca)

4 = Never easily (Nunca)

Ø  How satisfied were you with your ability to achieve orgasm? (Que tan satisfecha está usted con su habilidad de llegar a tener un orgasmo)

1 = Highly (Mayormente)

2 = Moderately (Moderado)

3 = Slightly (Pocas veces)

4 = Not at all (Nunca)

Ø  How satisfied were you with the intensity of your orgasm? (Que tan satisfecha está usted con la intensidad de su orgasmo)

1 = Highly (Mayormente)

2 = Moderately (Moderado)

3 = Slightly (Pocas veces)

4 = Not at all (Nunca)

BIENESTAR SEXUAL FUNCTION QUESTIONNAIRE(PART C)

Please read each question below and circle the ONE number that best describes your feeling and performance.

(Leer cada pregunta y circule el número que más le describe sus sentimientos)

FOR MEN ONLY:

*During the past week: (Durante la semana pasada)

Ø  How often did you have an erection? (Cuantas veces ha tenido una erección)

1 = Often (Frecuentemente)

2 = Sometimes (Algunas veces)

3 = Rarely (Casi nunca)

4 = Never (Nunca)

Ø  Describe your ability to have an erection (Describa su habilidad de tener una erección)

I = Always able to achieve (Siempre)

2 = Able to achieve most of the time (Casi todo el tiempo)

3= Able to achieve much of the time (Mayoría del tiempo)

4 = Able to achieve some of the time (Algunas veces)

5 = Never at le to achieve (Nunca)

NO / YES (Si) Circle one (Circule uno)

Ø  If you were able to have an erection, could you maintain its long as necessary to have intercourse? (Si usted tiene una erección pudiera mantener la el tiempo necesario para tener coitus) NO / YES 

Ø  Did erection take a long time to achieve?(Demora en tener una erección)

 NO  / YES 

Ø  Did you experience any difficulty with ejaculation? (Usted ha tenido dificultades con  eyaculación)

NO / YES 

Ø  How often did you have orgasm with little or no ejaculation?(Cuantas veces ha tenido usted poca o no eyaculación)

1 = Always (Siempre)

2 = Usually (Mayoría del tiempo)

3 = Frequently (Frecuentemente)

4 = Occasionally (Algunas veces)

5 = Rarely or never (Casi nunca)

Ø  How often was ejaculation delayed took a long time to ejaculate? (Cuantas veces la eyaculación se ha tomado un largo tiempo)

1 = Always (Siempre)

2 = Usually (Mayoría del tiempo)

3 = Frequently (Frecuentemente)

4 = Occasionally (Algunas veces)

5 = Rarely or never (Casi nunca)

Ø  How often did you ejaculate too quickly? (Cuantas veces se ha tenido una eyaculación precoz)

1 = Always (Siempre)

2 = Usually (Mayoría del tiempo)

3 = Frequently (Frecuentemente)

4 = Occasionally (Algunas veces)

5 = Rarely or never (Casi nunca)