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Questionair

University of Cincinnati
Medical Center

College of Medicine
Department of Internal Medicine

Division of Immunology
University of Cincinnati
PO Box 670563
Cincinnati OH 45267-0563

231 Bethesda Avenue (Pm 7562)
Phone (513) 558-4701

QUESTIONNAIRE FOR GULF WAR "BURNING SEMEN SYNDROME"

1.Do you experience a burning sensation during or after ejaculation? Yes No

2. Do you experience a burning sensation if you come in contact with your semen?Yes No

3.Does our sexual partner experience a burning sensation of her skin or vagina when she comes in contact with your semen?Yes No

4. Did this problem exist prior to being in the Persian Gulf War'?Yes No

5. If no, did this problem begin immediately alter returning from the Persian Gulf War after the first sexual encounter with your spouse or sexual partner'?Yes No

6. Does this burning sensation go away when you use a condom during sexual intercourse'? Yes No

7. If you experience this problem, have you sought medical attention?Yes No

8.Have you been treated for any sexually transmitted diseases since returning from the Gulf War such as gonorrhea, syphilis cytomegalovirus herpes virus, papilloma virus, hepatitis or human immunodeficiency virus?

9. If you and your sexual partner have experienced burning after contact with semen, would you be interested in participating in a study which investigates this problem further?Yes No

10. If you please note your name, age, wile or sexual partner's name and age along with your address, day phone, work phone and FAX if you have one.

NameAge

Wife or partner's nameAge

Address

Phone(day)(work)Fax

Thank you for answering this questionnaire If you have answered yes to these (questions, I will be contacting you in the near future with further details about participation in a study investigating burning semen syndrome

If you answered yes to any of these questions please fill out the next survey

If not thank you for your time

Patient Care Education Research. Community Service An Affirmation & Supplement;