| Personal Questions About How Pornography Affects You |
| Do you spend increasing amounts of time seeking out new pornography? | Yes No Doesn't apply
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| Do you seek out pornography when you feel upset, frustrated, tired or lonely? | Yes No Doesn't apply
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| After viewing porn, do you feel disconnected, depressed, frustrated, regretful, isolated, or alone? | Yes No Doesn't apply
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| Have you made promises to yourself that you will cut back your porn use, only to find yourself spending more and more time seeking it? | Yes No Doesn't apply
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| Have you ever deleted your porn collection, only to "restart" it over and over again? | Yes No Doesn't apply
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| Do you stay up late, or wake up early in order to view porn in privacy and not get caught? | Yes No Doesn't apply
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| Do you find yourself looking at progressively more destructive, violent, or disturbing forms of pornography over time? | Yes No Doesn't apply
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| Do you find yourself becoming desensitized to imagery that would have upset you when you first started looking at porn? | Yes No Doesn't apply
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| Do you find that no matter how many times you view porn, it is never enough, and you just can’t be satisfied? | Yes No Doesn't apply
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| Have you lost motivation, a spark for life, or clarity of thought? | Yes No Doesn't apply
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| Are you driven by anticipation of the next time you will look at porn, which overides other things you would normally look forward to? | Yes No Doesn't apply
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| Have you stopped enjoying pornography but still feel compelled to seek it out? | Yes No Doesn't apply
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| Relationship Questions About How Your Pornography Use Affects Those Around You |
| Do you find yourself avoiding family and friends and social activies to stay at home and view porn? | Yes No Doesn't apply
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| Do you find yourself endangering your job, reputation, etc. to view porn at work or other public places? | Yes No Doesn't apply
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| Is, or has, porn ever kept you from seeking a commited relationship? | Yes No Doesn't apply
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| Are you in a relationship, but prefer porn to being intimate with your partner? | Yes No Doesn't apply
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| While being intimate with your partner, do you find yourself acting out things you’ve viewed in porn? | Yes No Doesn't apply
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| Are your porn viewing habits secret from your family, friends, spouse, etc.? | Yes No Doesn't apply
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| Do you have trouble dealing with members of the oppisite sex, and seeing them as people, rather than objects, because of your porn use? | Yes No Doesn't apply
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| Does your porn use make your partner or spouse feel uncomfortable or inadequate? | Yes No Doesn't apply
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| Has your porn use made you isolated, or more distant from those you used to be close to? | Yes No Doesn't apply
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