Demographics

Name:   Date of Birth: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1968 1967 1966 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955
Contact Email:

Weight: (in pounds):      Height (in inches):  ***5 feet = 60 inches*** 60 61 62 63 64 65 66 67 68 69 70 71 72 (6ft)
Are you interested in a real-time medical fantasy examination?  Yes No
When are you available for examination : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 8:00AM 9:00AM 10:00AM 11:00AM 12:00PM 1:00PM 2:00PM 3:00PM 4:00PM 5:00PM 6:00PM 7:00PM 8:00PM 9:00PM 10:00PM 11:00PM 12:00AM
Hair Color: Brown Blonde Red Head Auburn Other Eye Color: Blue Brown Hazel Green Other
Measurements: Bust 30 32 34 36 38 40 42 >42 Cup AA A B C D DD >DD - Waist 28 29 30 31 32 33 34 35 36 37 38 >38 - Hips 32 34 36 38 40 42 >42 Dress Size: Size 0 Size 1 Size 3 Size 5 Size 7 Size 9 Size 11 > Size 11

Do you have any Body Piercings or Tattoos?: Location and Size
Have you ever been pregnant? Yes No If "YES" -How many times: 01 02 03 04 >4
How many imes have you given birth? 0 01 02 03 04 >4 Vaginal Cesarean Date of Last Birth: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / Year 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1987 1986 1985 1984 1983 1982 1981 1980
Do you have problems with Hemorrhoids? Yes No
Pubic Hair: Full/Natural Trimmed Shaved Would you like the Doctor to Trim/Shave your pubic hair?: Yes No
Does your current sexual partner know of your interests? Yes No
How does s/he respond?:
Do you have any bi-sexual tendencies? Yes No
If "Yes", describe them as they may relate to a medical fantasy or scenario.
How would you dress to visit the Doctor?

Have you ever participated in medical fantasy play before? Yes No
If "Yes" please describe your past experience(s). If "No" then please describe your interests (as well as they have been identified.)

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 below:

If 'NO', and this is something that you would like to experience,
please describe what you would like to occur:

Have you ever had a rectal examination? YES NO
If 'YES' did the Doctor use a rectal speculum, anoscope, or proctoscope? YES NO
Are you willing to have the Doctor watch you provide a urine sample? YES NO
Are your nipples sensitive to touch? YES NO If 'YES', please indicate what experiences you enjoy:
No Preference Stroking Pinching Pulling Biting Nipple Clamps Other
Have you ever been spanked? YES NO If 'YES', please describe the experience below:

If 'NO', would you like to be spanked? YES NO If 'YES', please indicate the items you would enjoy being spanked with: Hand Hair Brush Paddle Belt Other
What is the level of pain that you desire or can tolerate? Mild Moderate Intense
Do you feel the need to be disciplined? YES NO If 'YES', please expalin why and what you may feel is effective discipline:

Do you feel you need to be restrained? YES NO
If 'yes', please explain and specifically include the use of wrist and/or ankle restraints, blindfolds, gags, etc:

How frequently do you masturbate? Daily Several Times a Week Weekly As Often As I Can
What do you do that is particularly arousing?

Have you ever used a vibrator/dildo? YES NO If 'YES', please describe the experience:

Do you use the vibrator: externally, internally, rectally
Do you enjoy oral sex? YES NO If 'YES', to what extent: giving receiving both
If 'NO', why not:

Have you ever participated in anal sex? YES NO
If 'YES', to what extent: giving receiving fingers sex toy(s)
If 'NO', to what extent are you curious or interested? LOW MODERATE HIGHLY NONE
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:

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 woul like to have your temperature taken rectally, please indicate this preference:
-- Taking a patient's temperature rectally is standard procedure during a PLAY DOCTOR examination--
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 woul like to be given an enema, please indicate this preference. What type of enema equipment was/would be used?

Are you able to provide a witnessed urine sample? YES N


Do you want to be catheterized (urinary catheter)? YES NO
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: Hold CTRL key to select more than One Oral Vaginal Rectal
If 'NO', how would you relieve your arousal?

What was the date of your last GYN exam: mm/dd/yyyy M or F practitioner: M F
What was the date of your last period? mm/dd/yyyy
How regular are they? Like Clockwork Give or take a few days I can't remember
Do you use: Tampon Sanitary Napkin Both
* If you have had any gynecological surgery, please explain:

Is there anything else that you would like the Doctor to know before the examination commences?

Do you have any curiosity 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.