IMPACT Survey

Patients sometimes report changes in their sexual health.

Please respond to all of the statements below by selecting the number that best applies to you. There are no “right” or “wrong” answers. The information that you provide will remain strictly confidential.

1 = Not at all 2 = A little 3 = Quite a bit 4 = Very much N/A
1 = Not at all 2 = A little 3 = Quite a bit 4 = Very much N/A
1 = Not at all 2 = A little 3 = Quite a bit 4 = Very much N/A
1 = Not at all 2 = A little 3 = Quite a bit 4 = Very much N/A
1 = Not at all 2 = A little 3 = Quite a bit 4 = Very much N/A
1 = Not at all 2 = A little 3 = Quite a bit 4 = Very much N/A
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.