Self-Assessment Questionnaire
This questionnaire helps women self-assess their sexual health and identify any
concerns that may require medical attention. Please answer the following questions based on
your experiences and observations.
Scoring Instructions:
Add up the points based on your responses:
o Each “Decreased interest in sex” or “No interest in sex at all” : 1 point
o Each “Yes, occasionally” or “Yes, frequently” : 1 point
o Each “Sometimes” or “No”: 1 point
o Each “Rarely or never” : 1 point
o Each “Somewhat” or “No” : 1 point
o Each “Occasionally” or “Frequently” : 1 point
o Each “Mild” = 1 point, “Moderate” = 2 points, “Severe” = 3 points
What is your score?
 0-5 points:
o Symptoms Impact: Minimal concerns.
o Recommendations: Maintain a healthy lifestyle and monitor any
changes. No immediate medical attention required.
 6-10 points:
o Symptoms Impact: Mild concerns.
o Recommendations: Consider discussing concerns with a healthcare provider, especially if symptoms persist or worsen.
 11-20 points:
o Symptoms Impact: Moderate concerns.
o Recommendations: Schedule a consultation with a gynecologist or a specialist in sexual health to evaluate symptoms and discuss potential treatments.
 21+ points:
o Symptoms Impact: Significant concerns.
o Recommendations: Seek immediate consultation with a healthcare
