Client Sexual Hstory Questionnaire

Client Sexual History Questionnaire
This questionnaire may bring up uncomfortable feelings. It is very important information for me as your
treating professional to know in order to best assess and treat the issues that may be problematic for you.
One step in healing is to share comprehensive information to better understand the bigger picture. Some of
the questions may not apply to you for various reasons. If the question, does not apply, please move on the
next questions that does. Thank you for your time and honesty in answering these questions.
1. Do you believe that any of your sexual behaviors go against your value system? If yes, please
explain.
2. Do you feel confident in you sexual abilities? Please explain.
3. Do you have any problems with sexual function?
4. Have you ever been sexually molested or sexually abused or touched in an inappropriate way when
you were a minor? If yes then explain.
5. Did your caregivers ever talk to you about sex as a child that would be considered by today's
standards as appropriate and adequate? If no, then where did you find out information about sex as
a child?
6. At what age did you first masturbate? How did you learn about masturbation?
7. Have you ever masturbated to the point of injury?
8. Have you ever been injured while being sexual?
9. How old were you during your first sexual experience? What feelings do you have about that
experience?
10. How old was the person you engaged with sexually during your first sexual experience?
11. How many sexual partners have you had? (That includes vaginal, oral, masturbation, and anal sex)
12. Have you ever done things sexually that you regret? If so, please explain.
13. Do you have fantasies that cause you shame or discomfort? If yes then explain.
14. Have you had any Sexually Transmitted Diseases (STD) (examples: Herpes, HIV, Gonorrhea, Syphilis,
Chlamydia)
15. Have you given anyone a STD?

16. Have you ever had an abortion? If so how many and how old were you?
17. Have you ever been with someone who had an abortion?
18. Have you ever coerced anyone to be sexual?
19. Have you ever forced someone to be sexual?
20. Have you been coerced or forced to do anything sexual that you did not want to do?
21. Do you consider looking at pornography while in a committed relationship as infidelity? Does your
spouse?
22. Do you feel like your partner/spouse doesn't understand your sexual needs or desires?
23. Are you and your spouse on the "same page" sexually? If no, then explain.
24. Do you go for long periods of time without being sexual? Does your spouse or partner?
25. Have you ever looked at pornography? If yes, How often? Types or themes? Do you masturbate with
pornography usage?
26. Does your spouse or partner know fully about your pornography usage?
27. Do you or is it possible that you have children that your spouse or partner does not know about?
28. Do you feel sexually fulfilled/satisfied in your current sexual relationship? Please explain? If no, then
what would make it more fulfilling/satisfying?
29. Do you find the frequency of your sexual experiences satisfying with your partner/spouse? If no,
then explain.
30. Have you been sexual with anyone other than your spouse or partner while in a committed
relationship? If yes then explain.
31. Are there secrets that you keep from your spouse or partner? (i.e. sexual, financial, etc.)
32. Have you ever cheated on your spouse or partner?
33. Have you ever flirted with someone other than your partner?
34. Have you ever texted or sexted or used the phone or internet to communicate in an emotionally
intimate or sexually intimate way with anyone other than your spouse or partner?
35. Are you currently in a romantic and or sexual relationship currently than with your spouse or
partner?
36. Does your spouse or partner know about this relationship?
37. Have you ever exposed yourself inappropriately? If yes, then explain.
38. Have you ever “voyeured” anyone? if yes, explain.
39. Have you ever touched someone inappropriately? If yes, then explain.
40. Have you ever felt guilty about any sexual behaviors you have engaged in?
41. Have you ever engaged in any of the following, if yes please explain:
Role Play
Bondage/Domination/Sadism/Masochism BDSM
Water Sports (urination for sexual pleasure)
Swinging
Group sex or Orgy
Pornography
Bestiality
Prostitution/Escort (Buying or Selling)
Stripping (Buying or Selling)
Incest
Objectification
42. If you act out sexually, is there a common location or place where do you act out?
43. Do you have any of your technology (smart phone, laptops, tablets, tv, etc.) filtered? If so, with
what. If no, List all technology that you have access to.
44. Do you look at movies/videos, video games with sexual content?
45. Do you look at sites like YouTube or other video sites that aren't traditionally seen as porn sites for
pornography?
46. Have you been sexual with someone outside your sexual orientation that has caused you distress? If
so, please explain?
47. Have you ever been sexual with a person who is transsexual?
48. Have you dressed in the opposite gender's clothing for sexual purposes?
49. Have you ever had anonymous sex? If so how often?
50. Have you ever had sex with someone other than your spouse or partner in a hotel room?
51. Have you ever had sex outdoors or in public or somewhere there is the possibility to been seen by
others without their permission?
52. Do you use mood altering chemicals while being sexual?
53. Do you have any type of sexual dysfunction or shame or self-loathing about your sexual attributes?
54. Do you have any sexual rituals?
55. Do you overeat or restrict food after being sexual?
56. Would you consider yourself as having disordered eating patterns or an eating disorder?
57. Do you consider certain sexual behaviors bad or immoral? If so then explain?
58. Are there certain sexual behaviors that you consider compulsive?
59. Has your spiritual life been effected by your sexual behavior? If yes, how so?
60. Please briefly describe your experience filling out this questionnaire.
Thank you
Rawers Therapy

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Client Sexual History Questionnaire

2. Do you feel confident in you sexual abilities? Please explain.

3. Do you have any problems with sexual function?

7. Have you ever masturbated to the point of injury?

8. Have you ever been injured while being sexual?

15. Have you given anyone a STD?

18. Have you ever coerced anyone to be sexual?

19. Have you ever forced someone to be sexual?

32. Have you ever cheated on your spouse or partner?

36. Does your spouse or partner know about this relationship?

38. Have you ever “voyeured” anyone? if yes, explain.

44. Do you look at movies/videos, video games with sexual content?

49. Have you ever had anonymous sex? If so how often?

52. Do you use mood altering chemicals while being sexual?

54. Do you have any sexual rituals?

55. Do you overeat or restrict food after being sexual?

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