First Name*
Last Name*
Telephone number*
Email address*
Nationality* ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and/or BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatia (Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiKorea Democratic People's Republic ofKorea Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia Federated States ofMoldova Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia South Sandwich IslandsSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania United Republic ofThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican City StateVenezuelaVietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and Futuna IslandsWestern SaharaYemenYugoslaviaZaireZambiaZimbabwe
Age*
Gender* ---MaleFemaleOthers
Partner's Name*(first)
Partner's Name*(last)
Number of children from this relationship
Ages and genders
Number of children from previous relationship/s
Which children live with you?
What is your relationship status – married/partnership co-habiting/living separately?
Previous relationship history – brief description
What is the average frequency of your love making per month?
What is the average frequency percentage of full orgasm in the female partner?
What is the average frequency percentage of ejaculation in the male partner?
How comfortable are you in asking your partner for exactly what you want when making love on a scale of 0-10 where ‘0’ is uncomfortable and ‘10’ is very comfortable?
What were you taught about sex at home and at what age?
What were you taught about sex at school and at what age?
What was the general attitude in your home around the subject of sex? Was it spoken about in general or was it a hidden and embarrassing topic?
How would you rate your satisfaction with your current sexual life on a scale of 0-10 where ‘0’ is completely dis-satisfied an ‘10’ is completely satisfied.
Was this nurturing/helpful or how did you feel at the time?
Any other comments you think it would be helpful to express? Thank you for your openness and please finally share how it felt answering these questions. We greatly appreciate your willingness and can assure you of total confidentiality and respect with no judgement.
