SURVEY QUESTIONNAIRE DIRECTION: Put a check ( ) inside the box that

you think is the best answer for the corresponding

NAME (optional): ________________________ questions.

CASE STUDY TITLE: Levels of Satisfaction in CONSENT

Sexual Activities on Physiological well-being of
Adulthood 1. Agreement: I have read the procedure described
above. I voluntarily agree to participate in the
procedure and I have received a copy of this
Please read this consent document carefully before description.
you decide to participate in this case study.  Agree
 Disagree
INFORMED CONSENT
Purpose of the To determine the Levels of 2. If you are under the age of 18 parental consent is
case study: Satisfaction in Sexual needed and therefore you may not participate in
Activities on Physiological this case study.
well-being of Adulthood I hereby certify that I am 18 years of age or older.
What you will You will be asked to answer  Yes
be asked to do approximately questions on
 No
in the case questionnaire.
study?
Time required: 10 – 20 minutes DEMOGRAPHICS
Risks and You may experience emotions
Benefits: regarding sexual behavior. 3. Are you:
There are no potential benefits
 Male
to participating in this study.
 Female
Compensation: There is no financial
compensation for participating
4. How old are you?
in this case study.
 20 – 35 years old
Confidentiality: Your identity will be kept
confidential to the extent  35 – 50 years old
provided by law. No  50 – 80 years old
identifying information will be
obtained for you so that your 5. Who do you live with? (Please select all that
answers may not be traced back apply)
to you.  No one I live alone
Voluntary Your participation in this case  Roommates (no relatives)
Participation: study is completely voluntary.  Siblings / Relatives
There is no penalty for not  My Child (ren)
participating.  Parent (s) or Guardian (s)
Right to You have the right to withdraw  Spouse or significant other
withdraw from from the case study at any time
the study: without consequence. 6. Marital Status:
Whom to Diana Lozano, BS Psychology,  Single
contact if you 09183876249  Married
have questions Celyn Bea Allas,  Widowed
about the BS Psychology, 09081690440
study?
 SEXUAL SATISFACTION QUESTIONNAIRE The rating scale is as follows:

7. My partner (s) is / are: 1 Strongly Disagree

 Male 2 Disagree
 Female 3 Neutral
 Both 4 Agree
5 Strongly Agree
8. How long have you and your partner been
together?
 1 month - 12 months STATEMENT 5 4 3 2 1
 1 year – 5 years 11. I am disconcerted with
 6 years – 9 years a part of my sexual life.
 10 years and above 12. Sex is a source of
pleasure for me.
9. Have you been sexually active in the past year 13. Thinking about sex
(sexual activity refers to any type of genital generates negative
contact or sexual stimulation between two emotions
persons including, but not limited to sexual 14. I feel sexually
intercourse)? attractive.
 Yes 15. I find myself a poor
 No sexual partner
16. I do not have any
10. If you’re sexually active or have ever been problems in my sexual
sexually active, how many partner (s) have you life.
had total? 17. I like thinking about
 1–2 my sexual life.
 3–5 18. My sexual life
 6–9 frustrates me.
 10 and above 19. I am afraid I do not
satisfy my sexual
partner.
20. I find my sexual life
fulfilling.

OVERALL SEXUAL SATISFACTION

21. Are you satisfied with your marital sex life?

 Yes
 No

22. How would you rate your level of overall

satisfaction with your spouse / partner?
 Very Satisfied
 Satisfied
 Neutral
 Dissatisfied
 Very Dissatisfied

“Sex is something you do. Sexuality is something

you are.” – Anna Freud