US Healthcare Professionals

Instructions for Completing and Using the PEBEQ Form

1. Please answer all questions following the instructions on the front page
2. Please complete the form within 12 hours of a sexual event.
3. You can share the results with your partner, but you should not change your responses or answers.
4. You can share the PEBEQ form or test with your physician or healthcare provider so that they may assess your progress.
5. You should keep the information confidential until you are able to discuss with you healthcare provider.

(Note: Instructions for filling out the PEBEQ itself are provided on the form)

The PEBEQ questionnaire will be completed by the subject for all sexual encounters during the study. The questionnaire will be provided to the subject in the subject’s national language. The subject will be instructed to record the data in a diary card immediately after the encounter if possible or within 12 hours of the encounter, and to use the electronic date and time stamper to record the time of diary card completion. The PEBEQ is the first item in the diary card. The diary should be completed in the order in which the questions occur. The subject and the holder of the stop watch to measure IELT should be encouraged NOT to discuss the IELT until after all of the questions in the diary are completed.

Scoring of the two subscales – the Event Specific and General Domains – is completed by summing the score of the four items of the Event Specific Subscale, using the rating scores, creating a total score ranging between 0 and 16, with higher scores indicating greater levels of bother. Similarly for the General Subscale, the three items are summed creating a total score ranging from 0 to 12 with higher scores indicating greater levels of bother.