(Write below)
Brief Sexual History-Female
(This confidential Questionnaire is required by Dawn Michael M.A. Sex Therapist/Marriage Counselor.)
Name: _____________________________________________________
Tele.# H or W: _______________________
Address: __________________________________________________
Cell#: ____________________________
Email: ____________________________
Ok to send Mail? Yes/No
Ok to call? Yes/No
Date of Birth: ________
Relationship status: S/D/M/Sep.
Other:______________________________________________
Present sexual identity: Heterosexual/ Homosexual/ Bisexual/ Transvestite/ CD/Transsexual/ Other
Present living situation: Alone/with my spouse/ with a lover/ with friends/ with a roommate/ with my parents/ Other (specify):________________
Age of 1st sexual intercourse: _________
Age of 1st orgasm: _________________
Age of 1st period: _________________
Date of last orgasm: ___________________
Age of menopause*: ___* Type of hormone supplement used: (RX or natural/ OTC) _________________________; How long hormone supplement used? ____
**************************************************************
Write brief answers:
1.) What childhood messages about sex/sexuality did you receive growing up?
2.) Any concerns you may have about being pre-/ peri-/ post-menopausal?
3.) What have been your experiences with achieving orgasm? Alone? With a partner?
4.) What is your present pattern and frequency concening masturbation?
5..) How did and how do you feel about your body (as a child, growing up, as a young adult and now)?
6.) Describe the history of your sexual relationships: (Take extra paper or use other side if you need to; talk about the number of partners, what sexual activities you have experienced, and the issues and conflicts that have emerged for you in intimate relationships.)
7.) Describe any feelings you may have about having sexual contact with your present or possible sexual partner(s):
8.) Describe your present sexual interactions, such as intercourse or masturbation, turn-on’s, your present pattern for sexual pleasure, how often, your current number of partners, etc.:
9.) How often do you think about or desire to have sex?
___ 1x/ day
___ more than 4x’s/day
___ 1x/ week
___ more than 4x’s/ week
___ less than 4x’s/ month
10.) Do you want to work with a sex surrogate ? Yes or No
11) Are you currently seeing a psychotherapist or body worker? Yes or No
12) Do you have any pre-existing medical conditions that may affect your sexuality? (For example, diabetes, hypertension, heart disease…) Yes or No
13) Are you currently taking any prescribed medications, such as for hypertension, diabetes, depression, anxiety or cardiovascular disease? Yes or No
14) Do you drink or smoke more than moderately or use recreational drugs? Yes or No
15) Are you interested in using safe, natural products that can enhance your sexual experience? Yes or No
16) What is your primary goal for our work together?
I hereby release Dawn Michael M.A. or her associates for any damages that may result from sexual treatment: Yes – No – Not sure
Write here anything else related to your past or present experiences. Include anything that may be important for me to know, so that I may assist you toward reaching your sexual goals:
(Write below)
Brief Sexual History-Male
(This confidential Questionnaire is required by Dawn Michael M.A.)
Name: _____________________________________________________
Tele.# H or W: _______________________
Address: __________________________________________________
Cell#: ____________________________
Email: ____________________________
Ok to send Mail? Yes/No
Ok to call? Yes/No
Date of Birth: ________
Relationship status: S/D/M/Sep.
Other:______________________________________________
Present sexual identity: Heterosexual/ Homosexual/ Bisexual/ Transvestite/ CD/Transsexual/ Other
Present living situation: Alone/with my spouse/ with a lover/ with friends/ with a roommate/ with my parents/ Other (specify):________________
Age of 1st sexual feeling: ____________
Age of 1st wet dream: _____
Age of 1st masturbation:______________
Age of 1st sexual attraction: _______
Age of 1st date: ____________________
Age of 1st sexual intercourse: _________
Age of 1st orgasm: _________________
Date of last orgasm: ___________________
**************************************************************
Write brief answers:
1) What childhood messages about sex/sexuality did you receive? Of those, how might they affect your sexuality today?
2) What are any concerns you may have about your sexuality right now? (for example, feelings about your sexual performance, relationship, body or masturbation)
3) What are any concerns you may have about being male?
4) What have been your experiences with orgasm? Alone? With a partner?
5) What have been your experiences with self-pleasuring or masturbating?
6) What is your present pattern and frequency for self-pleasuring/ masturbation?
7) How did and how do you feel about your body (as a child, growing up, as a young adult and now)?
9) Describe any feelings you may have about having sexual contact with your present or possible sexual partner(s):
10) Describe your present sexual interactions, such as intercourse or masturbation, turn-on’s, your present pattern for sexual pleasure, how often, your current number of partners, etc.:
11) How often do you think about or desire to have sex?
___ once a day
___ 2-3 times a day
___ more than 4 times a day
___ once a week
___ 2-3 times a week
___ more than 4 times a week
___ less than 4 times a month
12) Check below any of these which are sexual “turn-on’s” for you:
___ erotic/ porno magazines
___ erotic/ porno videos
___ fantasy during masturbation
___ phone sex lines
___ message parlors or happy endings
___ Online sex chats
___ Internet sex (live)
___ other online sex with others
___ prostitutes
___ female (or male) escorts
___ BDSM play
___ cross dressing
___ swinging clubs/parties
___ exotic dance clubs/strip clubs
___ voyeurism
___ exhibitionism
___ erotic books
___ romance novels
___ dirty talk
Other: __________________________
13) Do you want to work with a sex surrogate ? Yes or No
14) Are you currently seeing a psychotherapist or body worker? Yes or No
15) Do you want a referral to a psychotherapist or body worker? Yes or No
16) Do you have any pre-existing medical conditions that may affect your sexuality? (For example, diabetes, hypertension, heart disease…) Yes or No
17) Are you currently taking any prescribed medications, such as for hypertension, diabetes, depression, anxiety or cardiovascular disease? Yes or No
18) Do you drink or smoke more than moderately or use recreational drugs? Yes or No
19) Are you interested in using safe, natural products that can enhance your sexual experience? Yes or No
20) What is your primary goal for our work together?
I hereby release Dawn Michael and or her associates for any damages that may result from sexual treatment: Yes – No – Not sure
Write here anything else related to your past or present experiences. Include anything that may be important for me to know, so that I may assist you toward reaching your sexual goals: