My Dr.

Age _26___
Location -Midwest----------
Martial status -Single-----------
Health conditions -Easy-----------


(x)slim ()average ( )voluptuous ( )bbw
Measurements: (34)breast (28)waist (36)hips
Brassiere Cup Size: ( )A (x )B(x )C ( )D ( )DD ( )Larger
Breast Implants? (x)no ( )yes
Pubic Hair: ( )full ( )trimmed (x)shaved

GYNECOLOGICAL HISTORY AND DETAILS
Have you given birth? ( ) 1 ( ) 2 ( ) 3 ( ) 4 ( )more
If yes for birth, did you deliver vaginally? ()yes ( )no
If yes for birth, did you breastfeed? ()yes ( )no
Have you had a tubal ligation? ( )yes (x )no
Have you had a hysterectomy? ( )yes (x)no
Do you have regular menstruation? (x)yes ( )no
Do you use contraceptives? (x)yes ()no
Have you been fitted with an IUD? ( ) (x)no
Do you douche? (x)yes ( )
Do you do breast self-exam regularly? (x)yes ( )no
Do your nipples erect spontaneously? (x)yes ( )no
Do you experience nipple secretions? (x)yes ( )no
Does your clitoris erect spontaneously? (x)yes ( )no
Does your vagina lubricate spontaneously? (x)yes ( )no

SEXUAL HEALTH
Have you ever had an STD? ( )yes (x)no
If yes, please provide details:
Age of first pelvic exam? (about 16)years
Date of last pelvic exam? (2)month (2022)year
Practitioner: ( )male (x)female
Manual Breast Exam? (x)yes ( )no
Manual Internal Vaginal Exam? (x)yes ( )
Vaginal Speculum Exam? (x)yes ( )
Manual Recto-vaginal Exam? ( x)yes ()
Rectal Proctoscopic Exam? (x)yes ()no
Did you experience sexual arousal? (x)yes ( )no
Did you masturbate following Exam? (x)yes ( )no

BASIC SEXUAL HISTORY
Age of first masturbation: How long since most recent? 14 , today
Age of first orgasm: How long since most recent? 14 today
Age of first receiving oral: How long since most recent? 14 yesterday
Age of first vaginal intercourse: How long since most recent? 15 yesterday
Age of first anal intercourse: How long since most recent? not

PERSONAL SEXUAL RELIEF
How often do you masturbate? (x)daily ( )weekly ( )monthly
Have you ever used a vibrator? (x)clitorally (x)vaginally (x)anally ( )no
Have you ever used a dildo? (x)vaginally ()anally ( )no
Have you ever used a shower massage? (x)vaginally ( )anally ( )no
Have you inserted a vibrating egg? ( )vaginally ( )anally (x)no
Have you inserted fruits/veggies? ()vaginally ()anally ( x)no
Have you inserted a bottle? (xvaginally ()anally (n)no
Have you inserted a hairbrush? (x)vaginally ()anally ( )no
Have you inserted other objects? (x)vaginally ()anally ( )no
If yes, please list all objects and where: cucumbers front and back and other toys I see and like

SEXUAL EXPERIENCES
Do you have any bi-sexual tendencies? (x)yes ( )no
Have you had a female partner? (x)yes ( )no
Do you have submissive tendencies? (x)yes ( )no
Have you been with multiple partners at once? ( )no (x)male and female ( )2 males ()2 females ( )orgy
Have you ever done DP with 2 males? (x)no ( )vaginal and anal ( )double vaginal ( )double anal
Where have you been inseminated? (x)vaginal ()oral ()rectal (facial ()breasts ( )other
Preferred location to be inseminated? (x)vaginal ()oral ()rectal (x)facial (x)breasts ()other
Have you ever had a medplay experience? ()yes (x)no
Have you ever been fisted? (x)no ()vaginally ()anally
Have you ever been given an enema under erotic circumstances? (x)yes ( )no
Have you ever explored urethral stimulation (peehole play)? ()yes (x)no
Have you ever had sex while restrained? (x)yes ( )no

SEXUAL RESPONSES
Do you often experience multiple orgasms? (x)yes ( )no
Do you squirt (female ejaculation)? ( )yes ( x)no ()
Have you ever experienced a vaginal orgasm? (x)yes ( )no
Have you ever experienced a clitoral orgasm? (x)yes ( )no
Have you ever experienced a g-spot orgasm? (x)yes ( )no
Have you ever experienced a urethral orgasm? ( )yes (x)no
Have you ever experienced an anal orgasm? ()yes ( x)no
Have you ever experienced a cervical orgasm? (x)yes ( )no
Have you ever experienced a nipple orgasm? ()yes ( x)no
Have you become sexually aroused by filling out this form? (x)yes ( )no ,yes playing as I fill it out!
.
CONSENT TO TREATMENT
Please review the list of typical and specialized procedures select all of those that you authorize, pursuant to the advisory
The****utic Massage? (x)authorized
Examination While Restrained? (x)authorized
Buttocks Hand Spanking Response? (x)authorized
Manual Breast Exam? (x)authorized
Breast Elongation/Lift? (x)authorized
Breast Vacuum Enlargement? (x)authorized
Nipple Oral Response? (x)authorized
Nipple Suction Pump Response? (x)authorized
Nipple Clamp Response? (x)authorized
Vaginal Douche? (x)authorized
Genital Area Shaving? (x)authorized I am always shaved smooth
Labia Clamp/Spread Visual Exam? (x)authorized
Manual G-spot Response? (x)authorized
Manual Deep Internal Vaginal Exam (fisting)? (x)authorized
Vaginal Speculum Visual Exam? (x)authorized
Tunnel Plug Vaginal Visualization/Treatment? (x)authorized
Vaginal Birthing Simulation? (x)authorized
Vaginal Vibratory Response? (x)authorized
Vaginal Oral Response? (x)authorized
PC Muscle Tone Demonstration/Evaluation? (x)authorized
Observed Urine Specimen? ( )authorized
Enema Prior to Rectal Exam? (x)authorized
Rectal Temperature? (x)authorized
Manual Recto-vaginal Exam? (x)authorized
Rectal Speculum Exam? (x)authorized
Rectal Probe Exam? (x)authorized
Manual Deep Internal Anal Exam (fisting)? () NO
Tunnel Plug Rectal Visualization/Treatment? ()NO
Clitoral Oral Response? (x)authorized Yes please
Clitoral Vibratory Response? (x)authorized
Clitoral Suction Pump Response? (x)authorized
Pelvic area TENS (electrostimulation) therapy? (x)authorized
Urethral Temperature? ( )authorized
Urethral Dilation Capability Evaluation (sounding)? ( )authorized
Urethral Vibratory Response? ( )authorized
Bladder Irrigation? ( )authorized
Cervical Vibratory Response? ( )authorized