1. Your Gender (*)
MaleFemale
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2. Your Age Range (*)
18-21
22-25
26-29
30-39
40-49
50-59
60+

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3. Relationship Status (*)
Single
Dating
Living with Partner
Married

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4. How satisfied are you with your sex life? (*)
Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied

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5. How easy is it to talk about sex with your partner? (*)
Very Easy
Easy
Neutral
Difficult
Very Difficult

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6. How well do you understand your partner's sexual needs and desires? (*)
Fully Understand
Understand
Neutral
Don't Understand
Completely Clueless

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7. What gets in the way of your sex life? (Choose all that apply) (*)
Schedule
Children
Sexual Desire
Work
None of the above

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8. How many times a week (on average) do you have sex with your partner? (*)
0-1
2-3
4-5
5-6
6 or more

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9. How many sexual partners have you had in your lifetime (*)
1
2-3
4-5
6-7
8 or more

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10. On a scale of 1-10 how much do you struggle with sexual temptation? 1 being 'not at all' and 10 being 'a significant struggle (*)
12345678910
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11. In the past 6 months, which of the follwong have you engaged in? (check all that apply) (*)
internet pornography
intercourse outside of marriage
phone sex (paid or consensual)
pornographic movies and magazines
online sexual chat
sexual encounter with same gender
sex with a prostitute
sex with someone you’ve know less than a day
visited a strip club
sexual encounter under the influence of alcohol or drugs
None of the above

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12. What role does your faith play into your sexual choices? (*)
Extremely
Reasonable
Some
Very Little
None at All

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