The BDSM EmblemPage 4 of 28

I have had sexual contact with the following:
Strangers Same Gender Person Opposite Gender Person
Animals Prostitutes Massage Providers
Inanimate Objects Co-workers Good friends
Your Boss Your Ex-Spouse Group of people
Disabled People Dead persons or animals None of the above

I have had the following sexually transmitted diseases:
HIV Gonorrhea Syphilis
Genital Warts N.G.U. Chlamydia
Hepatitis B Herpes P.I.D.
Other None  

During the past two years I have had the following sexual difficulties:

Low sexual desire Unable to climax Painful sex
Emotional strain during sex Performance Anxiety Unable to have an erection
Unable to maintain an erection Not lubricating Orgasm to soon
Delayed orgasm None  

I masturbate in the following ways:
Using own hand Using a vibrator Using lubrication
While watching porn While reading erotica While looking at pictures
When I wake up Before I go to sleep When ever
While touching my anus While touching my nipples None of the above

I masturbate in the following places:
In my bed In my lovers bed In a swimming pool
Fully Clothed Partially Clothed In a Hot Tub
In Public In the dark With lights on
In the Bathroom In the Kitchen In the Garage
In the back yard At the computer At the beach
At School At Church Other

The reasons I have abstained from sexual intercourse are:
Fear of pregnancy Fear of being intimate Fear of getting an STD
No one is good enough Not attracted to anyone Religious belief
Low self esteem Not ready to get serious Spouse refuses
Prefer alternate forms of sex (fetishism, BDSM, etc) Hate it Low sex drive
Feel guilty Lack of opportunity None of these

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