Sexual History Questionnaire

    Basic Information

    Provide only the information you’re comfortable having me know when we meet. If you prefer, I am happy that we both complete the form in your first session. You only have to fill in the form to the extent that you wish. You can also send me a voicemail for some or all of the questions if that feels more comfortable for you. After filling in the form, please click the send button at the bottom of the page, thank you.

    City:

    Age:

    Relationship/s Status:

    Gender Identity:

    Gender of Current Partners:

    Sexual Orientation:

    I heard about your services through:

    Sexual History/Experience

    Briefly describe your attitudes, thoughts, feelings, or perceptions about the following:

    Your body

    Sex

    Masturbation

    Mutual Masturbation

    Oral Sex

    Anal Stimulation/Massage/Sex

    Orgasm

    Being in a Relationship

    Your relationship with yourself

    Pornography

    Dressing up/ Role Play

    Toys and Sex Accessories

    Sexual Fantasy

    1. Please describe the sex education and messages you received about sexuality when you were growing up, and comment about the ways in which this may still effect you.

    2. Currently, I am experiencing (check all that apply):
    Lack of arousal or interestDifficulty achieving orgasm with partner/aloneErectile difficultyLack of genital sensationBoredom in my sex lifeInability to sexually satisfy myselfPain upon intercoursePoor body-imageInability to sexually satisfy my partner/ to be sexually satisfied by my partnerInability to communicate about my sexual needs, or to know what these areReliance on troublesome, repetitive or limited fantasies or turn-onsFears around sexual contact or activitiesDelayed or rapid ejaculationDecreased sense of connection with partnerVaginal dryness or other issuesOther

    Other:

    3. Are you seeing a doctor for any of the above?
    YesNo

    4. If you answered yes to #3, would you like me to be in touch with him/her to better meet your needs? If so, please provide the name of your doctor:

    5. What is your sex life like now? What is good/great/ ok about it now? What would make it better? What would your ideal Sex life look like?

    6. What images/fantasies/scenarios are most likely to arouse you? Describe the most intense point when you are most likely to orgasm. What is it that makes it so arousing for you?

    7. How do you feel about your fantasies?

    8. Please describe your current sex drive and what you feel about it

    9. Describe your most satisfying or exciting erotic/sexual experience? What made it so satisfying/exciting/ emotionally fulfilling for you?

    10. If you are currently in a relationship, does your partner know you are seeking coaching sessions? If not, what’s stopping you letting them know? If you are currently in a relationship, would you be interested in including your partner in this process? If you are currently in a relationship, do you think your partner would be interested in participating in this process?

    11. Is there any difference between your ability to orgasm when masturbating and when with a partner, and the kind of orgasm you experience? How satisfying is each experience? What would make it better? How would you like each to be ideally?

    12. What, if anything, do you feel is missing from your sex life?

    13. Do you have a sense that you have a wider range of sexual feelings and activities than you currently express? What might these be?

    14. Please describe your awareness of your sexual needs and your ability to communicate this to a partner:

    15. Do you feel comfortable about receiving Bodywork? What would make this a safe and welcome experience for you?

    16. Please advise which of the following statements would represent the most satisfying sexual experience for you:
    (a) when making love, I felt completely happy within my experience of my body and all my sensations and emotions. It was like everything else dropped away(b) when making love I felt deeply connected with my partner(c) when making love I felt completely free, playful and happy, as if I could do anything

    If none of these statements represents the most satisfying sexual experience for you, please describe what would:

    17-1. Here are some examples of what clients at times want to work on, but the list is nearly endless, and I also work with non-sexual or body related issues. Tick any of the following that may be of interest to you, or tell me about your objectives in the box marked “Other”
    17-2. Please note that there is no obligation to do anything. Any bodywork will be discussed and agreed in advance. We will always go at your pace.

    Understanding my bodyBecoming more comfortable with my bodyUnderstanding my partner’s bodyFinding pleasure for myselfExperiencing energetic alternatives to ejaculationMoving beyond reliance on sexual fantasyFinding and Communicating my needs and desiresExperiencing arousal in a relaxed stateConnecting with a partnerBuilding connection and intimacy with a partnerHow to be a better loverMasturbation coachingIncreasing sexual satisfactionExtending/expanding orgasmic statesSexual explorationProstate explorationLearning about/exploring my genitalsLearning about TantraBringing more variety to my sex lifeWork on a troublesome turn-on or fantasyUsing sexual aidsLearning to be more open and relaxed

    Other:

    18. Difficult things I want you to know about my sexual/sensual history are:

    19. Wonderful things I want you to know about my sexual/sensual history are:

    20-1. Tell me about your experience with counselling, coaching or bodywork, if any:

    20-2. What was helpful or least helpful?

    21-1. Have you had any erotic bodywork experience (sexological body worker, sensual massage, sex worker, surrogate, Tantrika, other).

    21-2. What was most helpful or least helpful?

    22. Your learning objectives for the first 3-5 sessions might be:

    23. Where you want to focus first is:

    24. What you need from me is:

    25. How you need me to be with you is:

    26. Are there any medication or substances you take regularly:

    27. Please add anything else you think is important for me to know. If you need to expand on anything from the “Currently, I am experiencing..” box, please add here

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