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*My heritage has a bearing on my sex life
A great deal
Somewhat
Not a lot
Not Sure
Not at all
N-C
*Total Lifetime sex partners
Zero
One
2-5
6-10
11-25
26-50
51-100
101-250
251-500
500+
I lost count
*Age I lost my virginity
10 or younger
10-12
13-15
16-18
19-21
22-30
30+
I am still a virgin
N-C
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 have been unfaithful to my exclusive lover / partners how many times
25+
10-25
2-9
once
never
N-C
*I have had a test for HIV - Aids
Yes
No
N-C
*I use a condom with my lover / partner
Always
Often
Sometimes
Rarely
Never
N-C
*I use other forms of birth control
Always
Often
Sometimes
Rarely
Never
N-C
*I feel guilty about my sexual past
Always
Often
Sometimes
Rarely
Never
N-C
*I masturbate how often
Non-stop
Dozens a day
A few a day
A couple a day
Once a day
Few a week
Once a week
a few a month
Once a month
Never
N-C
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
*Sex with my lover / partner occurs
4 or more times a day
2-3 times a day
Once a day
4 or more times a week
2-3 times a week
Once a week
2-3 times a month
Once a month
Lucky if its once a year
Never
N-C
*Sex usually lasts
Less than 5 minutes
5-10 minutes
11-20 minutes
20-30 minutes
31-60 minutes
More than 60 minutes
N-C
*I abstain from having sex
Always
Often
Sometimes
Rarely
Never
N-C
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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