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Part 1: General Information - check all that apply

1)SM scene experience -
a) novice b) experienced
A
2)Sexual orientation -
a)heterosexual b) bicurious c)bisexual d)gay
a
3)Gender orientation -
a)male b)female c) crossdresser d) transexual
a
4)Dominant -
a) always b) often c) rarely d) never
C
5)Submissive -
a) always b) often c) rarely d) never
b
6)Massochistic -
a) very b) somewhat c) hardly d) no, those people scare me
B
7)Sadistic -
a) very b) somewhat c) hardly d) no, those people scare me
B
cool main interest -
a) sensual-physical (bottom/top)
b)psychosexual-mental (dominant/submissive role play)
c)both are equally important
C
9)Will play at -
a) anywhere
b) my house/apartment
c) outdoors
d) parties
e)at SMclubs
f)public - near my home
g)public - a safe distance from home
B
10)Who can know of your activities -
a)I'm so discreet i don't even know what I am doing
b)Private play-only my partner needs to know
c)A few very trusted friends
d)Other scene people can know
e)Willing to be in Madonna's next book
c
11) How do you feel about other people in your scene -
a) I only play with myself
b) just me & my partner
c) threesome
d) small groups
e) the more the merrier
f) pre-approved people only
b
12) How do you feel about service (cleaning, errands, etc. ) -
a) I live to serve
b) Helping my dominant in little ways makes me feel good
c) It is part of the fantasy, but don't overdo it
d) Exploitive nonsense, I will do what is fun
c
13) How do you feel about punishment -
a) It is part of training and a right of the dominant
b) penalties for "disobedience" enhance the fantasy
c) It can be be okay as an excuse to have fun
d) Pointless; mutual pleasure needs no justification
b
14) What bruises or body marks are acceptable -
a) leave my body as is or i call my lawyer
b) temporary redness- gone in a few hours
c) occasional accidental bruises are okay
d) i expect to carry souvenir bruises for a week
e) my a** should look like a road map of Chile
b

Sample roles: Amazon*Baby*Barbarian*b***h-goddess*Boss*Burglar*Child*Clergy*Cowboy(girl)*
Daddy*Doctor*Evil Priest(ess)*Femme Fatale*French Maid*God(ess)*Hooker
*Indian*Ingenue*Inquisitor*Hero*Kidnap Victim*Knight*Leather-Macho*Master*
Mentor*Mistress*Mommy*Nun*Nurse*Rapist*Role Reversal*Perils of Pauline*
Pet*Pimp*Pirate*Policeman*Ponygirl(boy)*POW*Prince(ss)*Principal*Prisoner*
Puppy*Sage*Savage*Scientist*Secretary*Sex Object*Sissy*Slave*Slave Owner
*Slut*student*Suspet*Teacher*Teen*Torturer*VictIm*Warrior*Wild Beast

Roles I want to play (using above list & own ideas):
Slave

Roles i want a partner to play:
Godess!!!
Fetishes(example: foot worship, body types):
none anymore

Wants & perceived needs:
cuddling!!!

Medical, physical, or emotional concerns(past breaks, sprains, chronic conditions, phobias):
being left alone

Limits:
beating with tools and/or anywhere besides a**

Part 2: Preferred Activities

A list of some scene activities with typical responses. Pick the closest response and use the answers dom (D) and sub (S) enter number (or symbol) indicating their level of interest.

(1) Yes!! (pant, drool)
(2) Mmmmmmm, I like this
(3) Doesn't excite me, but i'd do it for you, darling
(4) Absolutly not, i will call the cops
(*) Intriguing, but scary; would push my limits
(!) Embarrassed to admit wanting/force me, please!

S D Corporal
______1. spanking (hand)3
______2. leather paddle*
______3. wodden paddle4
______4. belt/strap3
______5. switch2
______6. deerskin cat*
______7. leather cat*
______8. braided cat*
______9. rubber whip*
______10. knotted whip*
______11. single lash*
______12. taws*
______13. cane (rattan)4
______14. fiberglass/plastic rod4444
______15. riding crop1
----------Bondage--------
______16. mental bondage1
______17. silk scarves1
______18. nylon rope2
______19. cotton rope1
______20. chains1
______21. leather bonds1
______22. spandek bonds3
______23. plastic wrap3
______24. body bags4
______25. gags3
______26. leather cuffs3
______27. steel shackles2
______28. arm sleeves1
______29. straight jacket111
______30. breast bondage1
______31. genital bondage4
______32. infibulation?
______33. spreader bars3
______34. ceiling/wall hooks2
______35. cages1
______36. slings/swings1
______37. stocks/pillory1
______38. crosses4
______39. suspension (on toes)3
______40. suspension (full)3
______41. outdoor setting!
______42. indoor setting1
______43. public setting4
______44. semi-public setting4
______45. private setting1
______46. 1-3 hour duration1
______47. 3-6 hour duration1
______48. overnight duration1
----------Torture & Sensory Deprivation----------
______49. blindfolds1
______50. hoods1
______51. headphones/ear-plugs1
______52. tickling1
______53. feathers & fur1
______54. sexual teasing1
______55. sexual denial1
______56. chastity belt4
______57. pinching2
______58. hair pulling3
______59. n****e clips3
______60. clothes pins3
______61. genital torture4
______62. weights*
______63. c**k rings*
______64. ball stretchers4
______65. water torture4
______66. ice1
______67. oils, lotions, spices1
______68. hot wax1
______69. fire & ice1
______70. needles1
______71. cuttings3
______72. abrasion3
______73. electric torture!
----------Sex----------
______74. digital sex2
______75. directed masturbation1
______76. vaginal sex I hope
______77. oral sex I hope
______78. vibrator/d***o 3
______79. strap-ons3
______80. a**l sex3
______81. a**l plug3
______82. multiple penetration4
______83. analingus?
______84. vaginal fisting3
______85. a**l fisting4
______86. fantasy rape2
______87. directed bisexuality3
______88. threesome4
______89. group4
----------Humiliation & Exhibition----------
______90. foot kissing1
______91. kneeling1
______92. crawling1
______93. lead on leash1
______94. dirty words1
______95. verbal abuse1
______96. public embarrassment1
______97. face slapping2
______98. crossdressing4
______99. secret sex in pblic3
______100. public display4
______101. public sex4
______102. public whipping4
______103. infantilism?
______104. golden shower3
______105. enema*
----------Dress & Adornment------
______106. innocent1
______107. slutty1
______108. prim & proper1
______109. ultra-feminine1
______110. official domina goddess uniform1
______111. french maid1
______112. child/baby1
______113. slave1
______114. macho1
______115. biker1
______116. leathe1r
______117. spandex1
______118. rubber/latex1
______119. masks/hoods1
______120. costumes1
______121. lingerie1
______122. garters/stockings1
______123. corsets/cinches1
______124. boots1
______125. high heels1
______126. tattooing1
______127. body piercing1
______128. branding1

Comments & added items:


How do you like it? (use all that apply):
(N) never (T) thuddy (S) stingy (L) light (M) medium (ouch) (H) heavy (hurts) (?) unsure
?
Part of body: bondage corporal torture
back & shoulders
bottom & thighs
breasts & chests
feet & ankles
wrists

Part 3 - Checklist (we have disscussed):
_X_ Limits and safe words
__X Exclusivity and depth of relationship
_X_ Sex and birth control
_X_ Safer sex - current health (infectious diseases, HIV, STDs, herpes), testing, preventative measures (condoms, dental dams)