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The Dr. Susan Block Institute

for the erotic arts & sciences

8306 Wilshire Blvd. Suite 1047 Beverly Hills, Ca. 90211 213.749.1330

Director: Susan Marilyn Block, Ph.D.

Patient Questionnaire

Please take your time to answer the following questions. Answers to essay questions can be as brief or detailed as you like. You may skip entire questions, if you wish. However, the more details you can provide, the better your experiences with The Dr. Susan Block Institute will be.

You do not have to be a patient with the Institute to fill out this questionnaire. The questionnaire is also the basis for a survey that the Institute is conducting on people’s sexual experiences and fantasies. Therefore, we encourage all types of people to fill it out, whether you seek sex therapy or not. After we have received about 3000 completed questionnaires, the information will be processed by the Institute. The results of the survey will be published on the Institute website at drsusanblock.com.

    General Information

    1. Name:

    2. Address:

    3. City, State ZIP:

    4. Telephone:

    5. Email:

    6. Gender:

    7. Date of Birth:

    8. Place of Birth:

    9. Weight:

    10. Age:

    11. Race:

    12. Education/Major:
      (ie., high school grad, masters in business, doctorate in philosophy, etc.)

    13. Occupation:

    14. Employer:

    15. Income Level:

    16. Marital Status:
      (married, single, divorced, widowed, living with lover, etc)

    17. Children:

      If so, give age and gender:

    Medical Background

    1. Have you ever been hospitalized for any reason?

      If so, please describe, including the age at which hospitalization took place.

    2. Do you have any allergies?

      If so, please describe.

    3. Do you have any chronic illnesses?

      If so, please describe.

    4. Are you currently or have you recently been on any medication?

      What kind:

    5. Do you use any recreational drugs or alcohol?

      Please describe.

    6. Do you have any phobias?

      Please describe.

    7. Have you ever been in any kind of therapy--sexual or otherwise--before?

      If so, please describe the kind of therapy, how long you were in therapy, etc.

    General Family Background

    1. Who raised you (ie., father and mother, aunt, uncle, foster parents, nanny)?

    2. Briefly describe your relationships with whoever raised you.

    3. What is the nature of your current relationship with whomever raised you?

    4. Describe your upbringing (ie., liberal, conservative, loving, strict, confusing, pro-sex, anti-sex, bohemian, religious, etc.)

    5. How many brothers or sisters do you have?

    6. Describe your relationships with them while growing up and now.

    7. With what religion were you raised as a child?

    8. How observant?

    9. What religion do you now practice?

    10. How strict?

    11. How would you describe your relationships with peers--in and outside of school--while you were growing up?

    Early Sexual Development

    1. Describe the earliest sexual experience(s) that you can remember. How old were you?

    2. How old were you when you had your first orgasm (the first you can remember)? What were the circumstances?

    3. How old were you when you first felt sexually attracted to someone? What were the circumstances?

    4. How old were you when you first did any kind of sexual touching with another person? What were the circumstances?

    5. How old were you when you first had sexual intercourse? What were the circumstances?

    6. Describe the most significant sexual experience(s) of your childhood and/or adolescence.

    7. Describe one of the most significant sexual fantasies of your childhood and/or adolescence.

    8. Describe the "climax"--the most intense point of excitement--of this fantasy.

    9. What are some of your ideas about what made this fantasy so exciting for you?

    10. Did you ever have sex with any family members? Please describe.

    Personal Sexuality

    1. During the last year, how many times have you had sex with a partner in an average month (any sexual contact, not necessarily intercourse)?

    2. How many times would you like to have sex with a partner in the average month?

    3. Currently, how many sexual partners do you have? Be approximate, if necessary.

    4. Approximately how many different sexual partners have you had in your lifetime?

    5. How would you describe your sexual orientation?

    6. When you have sex with a partner, about what percentage of the time do you have an orgasm?

    7. Overall, on a scale of 1-10 with 1 being "very unhappy" and 10 being "extremely satisfied," how satisfied are you with your current sex life?

    8. Overall, on a scale of 1-10, how would you rate your level of self-esteem?

    9. How often do you masturbate? (per day, week or month)

    10. Do you have a special way or place in which you like to masturbate? Please describe.

    11. How many minutes do you usually spend masturbating in one session?

    12. Describe one or two of your most significant adult sexual experiences.

    13. Have you ever had sex with a sex worker (masseuse, prostitute, dominatrix)?

      Please describe.

    14. How do you like to dress for sex (or "dress sexy")?

    15. What's your favorite color?

    16. What's your favorite fabric?

    17. Are you comfortable with your gender?

      Please explain.

    18. Describe one of your most significant current sexual fantasies.

    19. Describe the "climax"--the most intense point of excitement--of this fantasy.

    20. What are your ideas about what makes this fantasy so exciting for you?

    21. For how many years have you been aroused by fantasies similar to the one you just described?

    22. Describe one or two of your other significant sexual fantasies.

    23. What does the word "pleasure" mean to you? What gives you pleasure? Be as general or specific as you like.

    24. Which are the most sensitive parts of your body? Please describe.

    25. Do you like to use sex toys (ie., dildos, vibrators, lingerie, erotica or pornography?)

      Please describe.

    26. What do you feel are your main sexual "assets"? (ie., looks, charm, warmth, humor, intelligence, wealth...)

    27. What do you feel are your main sexual "drawbacks"?

    28. What are your sexual inhibitions?

    29. Have you ever been forced to have sex when you didn't want to?

      Please describe.

    30. Have you ever forced another person to have sex with you when he or she didn't want to?

      Please describe.

    31. Have you ever been arrested because of your sexual behavior?

      If yes, what were you arrested for?

    32. Do you have any "sexual secrets"?

      Please explain.

    33. Are you shy?

      If so, in what way?

    34. Do you have any "sexual role models"?
      These may be real people that you know, fantasy characters or celebrities.

      If so, who are they? Why do you admire them and want to be like them?

    35. Is there anything about your sexuality that you wish you could change?

    36. What do you see as the purpose of your sessions with The Dr. Susan Block Institute? Be as general or specific as you like.

    Questions for People in Relationships Now (single people may skip these)

    1. How long have you been involved in your current relationship?

    2. Is your partner?

    3. Are you married, living together, dating, friends who have sex occasionally?

    4. How many times have you had sex with your partner in the last month (any sexual contact, not just sexual intercourse)?

    5. Since you became involved with this person, how many other people have you also had sex with (any sexual contact, not just sexual intercourse)?

    6. What are the best aspects of your relationship? Be as general or specific as you like.

    7. What are the worst aspects of your relationship?

    8. On a scale of 1-10, 10 being the highest, how would you rate your overall satisfaction with your relationship?

    9. On a scale of 1-10, how would you rate the sex in your relationship?

    Anything Else?

    1. Is there anything else about yourself, your sexuality, your goals or your fantasies that you'd like to add?

    The Dr. Susan Block Institute Established 1991

    For more information, call our recorded line.

    213.291.9497

    We’re available 24/7, including all holidays.

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