PRE-EXAMINATION INFORMATION FORM

*** FEMALES ONLY ***

All Patients are requested to complete this form prior to scheduling their examination. Your information will be kept in strict confidence. Please copy (cut & paste) and complete. E-mail completed form to:

  1. Are you interested in a real-time medical fantasy examination? YES (__) NO (__)
  1. When are you available for examination (How soon and preferred days & times):

______

  1. Name: ______
  1. Date of Birth: ___/___/___
  1. City/State of Residence: ______
  1. Weight: (in pounds): ______Height (in inches): ______

PLEASE NOTE:IF YOUR HEIGHT ISYOUR WEIGHT MUST NOT EXCEED

5’ 0”( 60” )132 pounds

5’ 1” ( 61” )134 pounds

5’ 2” ( 62” )136 pounds

5’ 3” ( 63” )139 pounds

5’ 4” ( 64” )141 pounds

5’ 5” ( 65” )143 pounds

5’ 6” ( 66” )145 pounds

5’ 7” ( 67” )147 pounds

5’ 8” ( 68” )150 pounds

5’ 9” ( 69” )152 pounds

5’ 10” ( 70” )154 pounds

5’ 11” ( 71” )156 pounds

6’ 0” ( 72” )158 pounds

  1. Hair Color: ______Eye Color: ______
  1. Measurements: ___ [__] -___-___ Dress Size: ______
  1. List any and all body piercings and tattoos: ______

______

  1. Have you ever been pregnant? YES (__) NO (__) If YES, how many times? _____
  1. If you have given birth, list a) the number of times; b) whether vaginally or by Cesarean; c) the date of your last birth. ______

______

DO YOU HAVE ANY PROBLEM WITH HEMORRHOIDS? YES (__) NO (__)

*YOU MAY INCLUDE A PHOTOGRAPH (REVEALING OR OTHERWISE) IF YOU FEEL SO INCLINED *

  1. Pubic Hair: Full (_) Trimmed (_) Shaved (_) Color: ______
    Would you like the Doctor to trim/shave your pubic hair? YES (_) NO (_)
  1. Does your current sexual partner know of your interests? YES (_) NO (_)
    How does s/he respond?______
  1. Do you have any bi-sexual tendencies? YES (_) NO (_) If "YES", please describe them as they may relate to a medical fantasy or scenario: ______
    ______
  1. How would you dress for the Doctor (before you are required to remove your clothes for the examination)? ______
  1. Have you ever participated in medical fantasy play before? YES (_) NO (_) If "YES", please describe past session(s); if "NO", please describe your interests (as well as they have been identified): ______
    ______
    ______
    ______
  1. Have you become aroused during an actual medical examination? YES (_) NO (_) If "YES", was the practitioner male or female? MALE (_) FEMALE (_). Please describe the experience:
    ______
    ______
    ______
    ______
    ______

If "NO", and this is something that you would like to experience, please describe what you would like to have occur.
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  1. Have you ever had a rectal examination? YES (_) NO (_) If "YES", did the Doctor use a rectal speculum, anoscope, or proctoscope? YES (_) NO (_)
  1. Are you willing to have the Doctor watch you provide a urine sample? YES (_) NO (_)
  1. Are your nipples sensitive to touch? YES (_) NO (_) If "YES",
    Please describe what you like: (nothing (_), stroking (_), pinching (_), pulling (_), biting (_), nipple clamps (_), etc.)
  1. Have you ever been spanked? YES (_) NO (_) If "YES", please describe the experience; if "NO", but you would like to be spanked, please indicate this preference and describe any implements that you would like to have used in addition to the hand. What level of "pain" can you tolerate and/or desire?
    ______
    ______
    ______
    ______
    ______
  1. Do you feel a need to be disciplined? YES (__) NO (__). If YES, please explain why and what you feel may be effective discipline: ______

______

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  1. Do you feel a need to be restrained? YES (__) NO (__) ? If YES, please explain and specifically include the use of wrist and/or ankle restraints, blindfolds, gags, etc.

______

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  1. How frequently do you masturbate? ______

What do you do that is particularly arousing? ______
______

Have you ever used a vibrator / dildo? YES (_) NO (_) If "YES", please describe the experience
______
______
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[do you use it superficially (_) or do you insert it into your vagina (_) and/or rectum (_) ]

Has completing this form caused you to get aroused? YES (__) NO (__)

  1. Do you enjoy oral sex? YES (_) NO (_)
    If “YES” , to what extent: giving (_), receiving (_), both (_)

If “NO”, why not? ______

  1. Have you ever participated in anal sex? YES (_) NO (_)
    If “YES”, to what extent: giving (_), receiving (_), fingers (_), sex toys (_)

If “NO”, to what extent are you curious or interested? ______

Have you ever inserted your finger into a man's anus/rectum? YES (__) NO (__) If you have done this, or want to do this, please explain: ______

______

______

  1. Within the past several years (3-5), have you had your temperature taken rectally? YES (_) NO (_)
    If "YES", please describe the experience; if "NO", but you would like to have your temperature taken rectally, please indicate this preference. --- Taking the patient’s temperature rectally is standard procedure during a PLAY DOCTOR examination ---
    ______
    ______
    ______
    ______
  1. Within the past several years (3-5), have you been given an enema? YES (_) NO (_)
    If "YES", please describe the experience; If "NO", but you would like to be given an enema, please indicate this preference. What type of enema equipment was/would be used?
    ______
    ______
    ______
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  1. Are you able to provide a witnessed urine sample? YES (__) NO (__)

Do you want to be catheterized (urinary catheter)? YES (__) NO (__)

  1. During an examination, is it possible that you would become aroused to the extent that you would request the Doctor to perform a sexual act with you? YES (_) NO (_). If "YES", what would you request?
    [ORAL, VAGINAL, ANAL] ______
    ______
    ______

IF "NO", how would you relieve your arousal?
______
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  1. When was the date of your last GYN exam? ___/___/___ MALE or FEMALE DOCTOR? M F
  1. When was the date of your last period? ___/___/___

How regular are they? ______
Do you use tampons (_) or sanitary napkins (_)?

* If you have had any gynecological surgery, please explain: ______

______

  1. Is there anything else that you would like the Doctor to know before the examination commences?
    ______
    ______
    ______
  1. Do you have any curiosity or interest in "reciprocating"; in other words, would you like to be the nurse/doctor? YES (__) NO (__). If YES, what are your curiosities/interests?

______

______

Thank you for your cooperation. Your answers will help the Doctor to more fully complete his assessment.