APPENDIX #1
QUESTIONNAIRE
Todays date____________ Code_____________
Introduction deleted
Please complete this questionnaire to the best of your ability.
Do not write your name so this
can remain anonymous. Thank you for your help with this research.
1. Age_________
2. What is your race? (Circle one)
White Black Asian Hispanic Other______________
3. What was the highest grade level you completed in school? __________
4. How many years of college (undergraduate) did you complete? __________
5. How many years of graduate school did you complete? __________
6. What degrees or certifications do you hold?__________________________
7. What is your occupation or profession?_____________________________
8. What is you estimated annual income? $____________________________
9. What is your religious background? (Circle one)
Catholic Protestant Jewish Muslim Buddhist Athiest Agnostic
Other__________________________________ None
10. How often do you attend religious services? (Circle one)
One or more times weekly Approx. once a month
One or two times yearly Never
11. How old were you the first time you knew about:
Age
Age
_____Masturbation
_____Homosexuality
_____Orgasm
_____Clitoris
_____Penile lengthening
_____Pregnancy
_____Menstruation
_____Penile enlargement Surgery
_____Sexual intercourse
12. Did you have a course in school that dealt with human sexuality?
Yes No
12A. If yes, was this course given in (Circle one):
Elementary school (K-6) Junior high school (7-9)
High school (10-12) Junior College Univ./College
12B. What percent of the information was NEW to you? ________percent
13. Which number on the scale best describes both your behaviors and
fantasies. (Circle the
number you feel is most appropriate)
1
2
3
4
5
6
7
Opposite sex
Equal same sex
Same sex
interests only
and opposite interests
interests only
14. Please circle one of the following to define yourself:
Heterosexual Bisexual
Homosexual Other________________________
15. How important is sex to you? (Circle most appropriate answer)
Very important Slightly important Somewhat
important Not at all important
16. How would you rate your general health? (Circle a number)
Great 1 2 3 4 5
Very Poor
17. Do you exercise on a regular basis?(Circle one) Yes
No
17A. If yes, how frequently? ____________________
17B. What types of exercise do you do?___________________________
18. What other cosmetic surgeries, of any kind, have you undergone?
_____________________________________________________________________________________
_______________________________________________________________________
BEFORE YOUR SURGERY...
19. Using the scale below, how would you rate your self concept or self
worth before surgery?
(Circle one number)
1
2
3 4
5
very good
neutral
very poor
20. How did you perceive your FLACCID penis size before surgery?(Check
one)
_____Much larger than average
_____Somewhat larger than average
_____Average
_____Somewhat smaller than average
_____Much smaller than average
21. How did you perceive your ERECT penis size before surgery?(Check
one)
_____Much larger than average
_____Somewhat larger than average
_____Average
_____Somewhat smaller than average
_____Much smaller than average
22. What were the dimensions of your penis before surgery (in inches)?
FLACCID: Length________ Circumference_________
ERECT: Length________ Circumference_________
23. How many hours of counseling or therapy did you have in the year
before your surgery?
(Fill in a number) _____times per day
_____times per week
_____times per month
_____times per year
_____Not applicable
23A. What percentage of the counseling was regarding penis size? _________%
24. How frequently did you engage in sexual activities, with or without
a partner, before your penile enlargement surgery?
(Fill in a number) _______times
per day
_______times per week
_______times per month
_______times per year
_______Never did
25. List your three most frequent sexual activities on the lines below.
1)____________________________________________________
2)____________________________________________________ 3)____________________________________________________
26. In general, would you say your overall sexual satisfaction (self-defined)
BEFORE SURGERY
was: (
Check one) _____Very much above average
_____Somewhat above average
_____About average
_____Somewhat below average
_____Very much below average
27. How long before surgery, did you consider a penile augmentation?
______weeks_______months______years
28. Why did you decide to change the size of your penis?__________________________________________________
_____________________________________________________________________________________________
29. Who else knew about your plans to get a penile enlargement or lengthening?
__________________________________________________________
30. Approximately, how long did you spend talking with your doctor BEFORE
the day of the
surgery?
(Fill in numbers) _____minutes_____hours _____Never
did
31. Approximately, how long did you spend talking with your doctor on
the day of the
surgery?
(Fill in numbers) _____minutes_____hours _____Never
did
32. How frequently, on average, did you masturbate before your penile
enlargement surgery?
(Fill in a number) ______times per day
______times per week
______times per month
______times per year
______Not applicable
33. How frequently, on average, did you engage in sexual relations with
members of the opposite sex before surgery ?
(Fill in a number) ______times per day
______times per week
______times per month
______times per year
______Not applicable
34. How often did you engage in sexual relations with members of your
same sex before
surgery ?(Fill in a number)
______times per day
______times per week
______times per month
______times per year
______Not applicable
ABOUT YOUR PENILE ENLARGEMENT SURGERY....
35. How long has it been since your first penile enlargement surgery?
_____weeks_____months_____years DATE:_____________________________
36. List other penile enlargement surgeries, DATES and Doctor’s name
_____________________________________________________________________________________
_________________________________________________________________________________________
37. Which surgery did you have performed? (Circle your first surgical procedure)
Penile Lengthening only Fat Injection into Penis (liposuction)
Autologous fat and lengthening
Dermal Fat graft and lengthening
(Fat liposucked and inserted into penis)
(Skin and fat from under buttocks)
Pedical Fat graft and lengthening
Don’t know
(Skin and fat from the stomach)
Other_____________________________________________
38. What is the name of the doctor who performed your first penile enlargement surgery?_________________________
39. Your age at time of initial penile enlargement surgery_______________
40. What city/state/country did you live in at the time of your penile enlargement surgery?__________________________
41. What city/state did you have the penile surgery in?__________________________________
42. How do you feel the PRE-OPERATIVE procedures rated(e.g. meeting
with doctor, nurse or technician, videos shown, medical testing, informational
packets)? (Circle the appropriate number)
Best 1 2 3 4 5 Worst
Describe procedures___________________________________________________________________________
___________________________________________________________________________________________
43. How do you feel the FOLLOW-UP procedures rated? (Circle the appropriate
number)
Best 1 2 3 4 5 Worst
Describe the procedure ________________________________________________________________________
___________________________________________________________________________________________
44. What would you say was your estimated time of recovery?(Your life
was back to normal)
Fill in a number.
______days _______weeks _______months ______Never was
45. Did your recovery time match the time your doctor predicted?
Yes No
If not, describe the difference_________________________________
______________________________________________________
AFTER THE SURGERY...
46. Did the surgical procedure match what you expected?
Yes No
Explain________________________________________________
______________________________________________________
47. Did you experience any infection or other problems after your penile
augmentation surgery?
Yes No
Explain________________________________________________
______________________________________________________
48. How do you perceive your FLACCID penis size after surgery?(Check
one)
_____Much larger than average
_____Somewhat larger than average
_____Average
_____Somewhat smaller than average
_____Much smaller than average
49. How do you perceive your ERECT penis size after surgery?(Check one)
_____Much larger than average
_____Somewhat larger than average
_____Average
_____Somewhat smaller than average
_____Much smaller than average
50. Did the penile enlargement live up to the expectations of how you wanted your penis to look?
LENGTH: Yes No
THICKNESS: Yes No
PROPORTION: Yes No
AESTHETICS: Yes No
(Scarring, curvature, lumpiness, etc.)
FUNCTION: Yes No
Explain your answers _____________________________________
______________________________________________________
______________________________________________________
51. What other procedures have you used to enhance your results?(weights,
stretching,
etc.)_______________________________________________
__________________________________________________________
52. What are the dimensions of your penis, currently (in inches)?
FLACCID: Length________ Circumference_________
ERECT: Length________ Circumference_________
53. Did you feel the surgery was successful?(Circle a number)
1
2
3
4
5
very successful
very UNsuccessful
54. How long did you wait after surgery before you showed your penis
to someone other than
a medical professional?
(Fill in a number) _______days_______months_______years
55. Who was that person? (Circle all that apply) Male Female Friend Relative Lover Other__________________
56. How many hours of counseling or therapy have you had in the last
year?
(Fill in a number)
_____times per day
_____times per week
_____times per month
_____times per year
_____Not applicable
56A. What percentage of the counseling was regarding penis size?__________%
ABOUT YOUR SEXUALITY AFTER SURGERY...
57. Using the scale below, how would you rate your self concept or self
worth AFTER surgery?
(Circle one number)
1 2
3 4
5
very good neutral
very poor
58. How frequently have you engaged in sexual activities, with or without
a partner, since your penile enlargement surgery and after healing?
(Fill in a number)
_______times per day
_______times per week
_______times per month
_______times per year
59. In general, would you say your overall sexual satisfaction (self-defined)
after surgery has been
(Put a check next to your answer):
_____Very much above average
_____Somewhat above average
_____About average
_____Somewhat below average
_____Very much below average
60. Did the surgical procedure change your erection in any way?(angle,
shape, firmness, size, scarring) Yes No
If yes, please describe.______________________________________
______________________________________________________
61. How long after your penile surgery did you attempt masturbation?(Fill
in a number)
_____days_____weeks_____months_____years
Never did_________
62. After surgery, did you experience pain during masturbation?(Circle
one)
Yes No
62A. If yes, how long after surgery did it go away?______________
63. How often do you masturbate since your penile enlargement surgery?
(Fill in a number)
_______times per day
_______times per week
_______times per month
_______times per year
_______Never did
64. How long after your penile surgery did you attempt sexual intercourse?
(Fill in a number) _____days_____weeks_____months_____years
Never did______
65. After surgery, did you experience pain during sexual intercourse?
Yes No
65A. If yes, how long after surgery did it go away?______________
66. How often have you engaged in sexual relations with members of the
opposite sex after
surgery ?
(Fill in a number)
_______times per day
_______times per week
_______times per month
_______times per year
_______Never did
67. How often have you engaged in sexual relations with members of your
same sex after surgery ?(
Fill in a number)
_______times
per day
_______times
per week
_______times
per month
_______times
per year
_______Never
did
68. Did you notice any difference in penile sensation after your surgery?(Circle
one)
Yes No
Explain________________________________________________
______________________________________________________
69. Did you notice any difference in ejaculation after your surgery?(Circle
one)
Yes No
Explain________________________________________________
______________________________________________________
70. How long were you told, by your doctor, to wait before attempting...
Masturbation__________
Oral sex______________
Vaginal sex___________
Anal sex_____________
Never told____________
71. Rate your first doctor on this satisfaction scale? (Circle one)
1 = very satisfied 5 = very UNsatisfied
A. Initial contact:
1 2 3 4 5
B. Interview:
1 2 3 4 5
C. Surgery:
1 2 3 4 5
D. Follow up:
1 2 3 4 5
72. If you had life to live over again, would you have the penile augmentation
surgery?
Yes No
73. Circle the more important aspect of penis size.
Length Girth
74. If you could magically “grow” the penis of your dreams, how long
would your ideal penis be?
__________ inches
75. How thick would your penis be? _________ inches in circumference
76. How many people do you know who have had a penile augmentation surgery?_____________
77. How many people do you know who are considering penile augmentation surgery?_____________
78. Would you suggest the procedure you went through to a friend?
Yes No
Explain________________________________________________________________________________________
79. What advice would you give to future patients? ______________________________________________________________________________________________
___________________________________________________________________________________________
80. Where did you find the doctor who performed your surgery (Advertisement, Referral, etc.)?_______________________
81. What was the cost of the penile augmentation surgery? $____________
82. How much was spent on other costs (travel, hotel, taxis)? $___________
83. Please list any other elective surgeries you have considered.
_____________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________
Please return this questionnaire in the enclosed stamped envelope to: (deleted)
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