SENSUAL EXAMS GROUP
PATIENT MEDICAL HISTORY AND PRE-EXAMINATION INFORMATION FORM
Your information will be kept in strict confidence. Please copy and complete, and then email back. All Patients are requested to complete this form prior to scheduling their examination.
PATIENT NAME:
PATIENT EMAIL ADDRESS:
PHYSICAL DETAILS
Height: ( )feet ( )inches
Build: ( )slim ( )average ( )a few extra pounds ( )bbw
Measurements: ( )breast ( )waist ( )hips
Brassiere Cup Size:
Pubic Hair: ( )dense ( )trimmed ( )shaved
Natural Hair Color:
AGE😢 ) teens ( ) 20’s ( ) 30’s ( ) 40’s ( ) 50’s ( ) will discuss later
YOUR EXAMINATION
Your examination will be exceedingly thorough and complete. In addition to the typical procedures, there specialized procedures recommended to ascertain the sexual health, function, and responsiveness of the patient. Some of these procedures might cause the patient to feel embarrassed or otherwise be reluctant to undergo them. In this case, the patient has the option to decline to authorize the procedure(s). Of course, should any procedure(s) not be authorized, the doctor's evaluation of the patient's sexual health, function, and responsiveness may be incomplete in the related area.
GYNECOLOGICAL HISTORY AND DETAILS
Have you given birth vaginally? ( )yes ( )no
Have you had a tubal ligation? ( )yes ( )no
Do you have regular periods? ( )yes ( )no
Have you had a hysterectomy? ( )yes ( )no
Do you douche? ( )yes ( )no
Menstrual Cycle:
Date of last period (beginning):
Length of typical menstrual period:
Typical timing between periods:
Date of last pelvic exam:
Practitioner: ( )male ( )female
Manual Breast Exam? ( )yes ( )no
Manual Internal Vaginal Exam? ( )yes ( )no
Vaginal Speculum Exam? ( )yes ( )no
Manual Recto-vaginal Exam? ( )yes ( )no
Rectal Speculum/Protoscope Exam? ( )yes ( )no
Did you experience sexual arousal? ( )yes ( )no
Did you masturbate following Exam? ( )yes ( )no
Do you do breast self-exam regularly? ( )yes ( )no
Do you lubricate spontaneously? ( )yes ( )no
Do your nipples erect spontaneously? ( )yes ( )no
Do you experience nipple secretion? ( )yes ( )no
Does your clitoris erect spontaneously? ( )yes ( )no
BASIC SEXUAL HISTORY
Age of first masturbation:
Age of first orgasm:
Age of first receiving oral:
Age of first performing oral:
Age of first vaginal intercourse:
Age of first anal intercourse:
SEXUAL ACTIVITIES
Do you have any bi-sexual tendencies? ( )yes ( )no
If yes, have you had a female partner? ( )yes ( )no
Do you often experience multiple orgasms? ( )yes ( )no
Do you squirt (female ejaculation)? ( )yes ( )no
Have you ever experienced a vaginal orgasm? ( )yes ( )no
Have you ever experienced a clitoral orgasm? ( )yes ( )no
Have you ever experienced a g-spot orgasm? ( )yes ( )no
Have you ever experienced a cervical orgasm? ( )yes ( )no
Have you ever experienced a urethral orgasm? ( )yes ( )no
Have you ever experienced an anal orgasm? ( )yes ( )no
Have you ever experienced a nipple orgasm? ( )yes ( )no
Do you masturbate? ( )yes ( )no
If yes, how often? ( )daily ( )2-6 days/week ( )weekly ( )rarely
Have you ever used a vibrator? ( )vaginally ( )rectally ( )no
Have you ever used a dildo? ( )vaginally ( )rectally ( )no
Have you ever used a shower massage? ( )vaginally ( )rectally ( )no
Have you ever used a vibrating egg? ( )vaginally ( )rectally ( )no
Have you inserted fruits/veggies? ( )vaginally ( )rectally ( )no
Have you inserted a bottle? ( )vaginally ( )rectally ( )no
Have you inserted a hairbrush? ( )vaginally ( )rectally ( )no
Have you inserted other objects? ( )vaginally ( )rectally ( )no
If yes, list all other objects used:
Birth Control
Do you currently practice birth control ( ) yes ( ) no
Type of birth control:
Please review the list of typical and specialized procedures and select those that you authorize, pursuant to the advisory statement above.
Examination While Restrained? ( )authorized
Manual Breast Exam? ( )authorized
Nipple Oral Responsitivity? ( )authorized
Nipple Suction Pump Responsitivity? ( )authorized
Vaginal Douche Prior to Exam? ( )authorized
Manual G-spot Responsivitity? ( )authorized
Manual Deep Internal Vaginal Exam? ( )authorized
Vaginal Speculum Visual Exam? ( )authorized
Vaginal Vibratory Responsitivity? ( )authorized
Vaginal Oral Responsitivity? ( )authorized
Observed Urine Specimen? ( )authorized
Enema Prior to Rectal Exam? ( )authorized
Rectal Temperature? ( )authorized
Manual Recto-vaginal Exam? ( )authorized
Rectal Speculum Exam? ( )authorized
Clitoral Oral Responsitivity? ( )authorized
Clitoral Vibratory Responsitivity? ( )authorized
Clitoral Suction Pump Responsitivity? ( )authorized
Ejaculatory Fluid Catheter Specimen? ( )authorized
Oral Penile Capacity Evaluation? ( )authorized
Vaginal Penile Capacity Evaluation? ( )authorized
Rectal Penile Capacity Evaluation? ( )authorized
If you are aware of any other conditions or relevant facts that the doctor should be aware of, or procedures which might be advisable, please list them below:
Thank you in advance for your time and attention to detail in providing this information.