#____________
__/__/__
(Write below)
Brief Sexual History-Female
(This confidential Questionnaire is required by Dr. Patti Britton, Sex Coach.)
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 erotic dream: _____
Age of 1st masturbation:______________
Age of 1st sexual attraction: _______
Age of 1st date: ____________________
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? Of those, how might they affect your sexuality today?
2.) What are any concerns you may have about your periods or pregnancy?
3.) What are any concerns you may have about being pre-/ peri-/ post-menopausal?
4.) What have been your experiences with achieving orgasm? Alone? With a partner?
5.) What have been your experiences with self-pleasuring or masturbating yourself?
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)?
8.) 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.)
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?
___ 1x/ day
___ more than 4x’s/day
___ 1x/ week
___ more than 4x’s/ week
___ less than 4x’s/ 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
___ Online sex chats
___ Internet sex (live)
___ Other online sex with others
___ prostitutes
___ male escorts
___ BDSM play
___ cross dressing
___ swinging clubs/parties
___ exotic dance clubs
___ voyeurism
___ exhibitionism
___ erotic books
___ romance novels
___ dirty talk
Other: __________________________
13) Are you interested in being trained in bodywork, such as masturbation or other sexual enhancement techniques? Yes or No
14) Do you want to work with a sex surrogate ? Yes or No
15) Are you currently seeing a psychotherapist or body worker? Yes or No
16) Do you want a referral to a psychotherapist or body worker? Yes or No
17) Do you have any pre-existing medical conditions that may affect your sexuality? (For example, diabetes, hypertension, heart disease…) Yes or No
18) Are you currently taking any prescribed medications, such as for hypertension, diabetes, depression, anxiety or cardiovascular disease? Yes or No
19) Do you drink or smoke more than moderately or use recreational drugs? Yes or No
20) Are you interested in using safe, natural products that can enhance your sexual experience? Yes or No
21) What are your long-term sexual goals?
22) What is your primary goal for our work together?
23) Are you willing to commit to your sexual success, do you agree to do the assignments and allow yourself to your sexual pleasure? Yes – No – Not sure
24) I hereby release Dr. Britton and or her associates for any damages that may result from sexual treatment: Yes – No – Not sure
25) 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:
For credit card use, please include the following:
Name on card:
Mail address: (if different than above)
Primary tele:
Primary email:
CC #:
Exp. Date:
Pin Code:
[Note that all credit card charges are made through Resources Unlimited, LLC, not Dr. Britton.]
Thank you!
Dr. Patti Britton, Sex Coach
