CONFIDENTIAL QUESTIONNAIRE FOR FEMALE / STUDENTS

Personal Details

Full Name:

Profession:

Date of birth:

Marital Status:
Single Married Widowed Separated Divorced

In a Relationship?:
Yes No

Number of Children:
0 1 2 3 4 5 6 7

How did you get to know me?:

Address:

Email:

Contact Number - Primary:

Contact Number 2 - *Optional:

Contact Number 3 - *Optional:

Preffered Method of Contact:
Post Mobile Email Not to contact

Name and address of doctor:

Are you free from sexual transmited diseases?:
No Yes

Questions

Do you suffer from or have you suffered from any of the following?

Allergies:
No Yes

Epilepsy:
No Yes

Heart Problems:
No Yes

Headaches:
No Yes

Hayfever:
No Yes

Blood Pressure Problems:
No Yes

Depression:
No Yes

Back Problems:
No Yes

Have you had any serious ilnesses / operations / psychiatric treatments / couselling or any other therapies over the last 5 years?:
No Yes

Have you taken any antidepressants?:
No Yes

What would you like to achive from Tantric Journey sessions?

Help with sexuality:
No Yes

Help with intimcay:
No Yes

Help with love:
No Yes

Find life long partner:
No Yes

Improve Existing Relationship:
No Yes

Any other:

What are your fears during the session?:

What are your boundries during the session?:

Related Stresses of life

DEATH OF A LOVED ONE:
No Yes

DIVORCE OR SEPARATION:
No Yes

LOSS OF A RELATIONSHIP
No Yes

PHYSICAL ILLNESS:
No Yes

DISABILITY:
No Yes

LOSS OF EMPLOYMENT:
No Yes

STRESS AT WORK:
No Yes

POVERTY / RETIREMENT:
No Yes

POOR HOUSING:
No Yes

GETTING OLD:
No Yes

GROWING UP:
No Yes

ADDICTIONS:
No Yes

TAKING CARE OF THE ELDERLY, SICK OR CHILDREN:
No Yes

EXAMS:
No Yes

RELATIVES MOVING AWAY:
No Yes

PROMOTION:
No Yes

DEATH OF A LOVED ONE:
No Yes

DIVORCE OR SEPARATION:
No Yes

LOSS OF A RELATIONSHIP:
No Yes

HAVING A BABY:
No Yes

GETTING MARRIED:
No Yes

CHILDREN LEAVING HOME:
No Yes

LEARNING DIFFICULTIES:
No Yes

LEAVING HOME:
No Yes

GOING ON HOLIDAY:
No Yes

HEAVY PHYSICAL WORK:
No Yes

LONG HOURS:
No Yes

POOR WORKING ENVIRONMENT:
No Yes

WORKING TO DEADLINES:
No Yes

CONSTANT TRAVEL:
No Yes

LONG HOURS:
No Yes

POOR WORKING ENVIRONMENT:
No Yes

GOING ON HOLIDAY:
No Yes

HEAVY PHYSICAL WORK:
No Yes

TOO MUCH RESPONSIBILITY:
No Yes

THE CRYING BABY:
No Yes

BEING UNHAPPY ABOUT YOUR APPEARANCE:
No Yes

BEING CONCERNED ABOUT YOUR SEXUAL IDENTITY:
No Yes

FEAR OF BEING RAPED OR ATTACKED:
No Yes

OTHER:

STRESS SYMPTOMS

FEELING CONSTANTLY EXHAUSTED:
No Yes

NO INTEREST IN LIFE:
No Yes

IRRITABILITY:
No Yes

LACK_OF_CONCENTRATION:
No Yes

CRYING_EASILY::
No Yes

ATTENTION SEEKING:
No Yes

HYPREACTIVITY:
No Yes

RAPID SPEECH:
No Yes

FEAR:
No Yes

RAPID THOUGHTS:
No Yes

THINK ABOUT FOOD A LOT:
No Yes

PARANOIA:
No Yes

PHOBIAS:
No Yes

FEELING OF GLOOM AND DOOM:
No Yes

FEELING LIFE IS NOT WORTH LIVING:
No Yes

RESTLESSNESS:
No Yes

DEATH OF A LOVED ONE:
No Yes

DIVORCE OR SEPARATION:
No Yes

COMPULSION:
No Yes

OBSESSION:
No Yes

TIGHT CHEST OR THROAT:
No Yes

SHAKING:
No Yes

DIZZINESS:
No Yes

DIARRHOEA:
No Yes

WIND:
No Yes

INSOMNIA:
No Yes

BREATHING DIFFICULTIES:
No Yes

THUMPING HEART:
No Yes

EXCESSIVE SWEATING:
No Yes

SWALLOWING PROBLEMS:
No Yes

LOSS OF APPETITE AND WEIGHT::
No Yes

HEADACHES:
No Yes

DIFFICULT TO EXPERIENCE REGULAR ORGASM:
No Yes

TINNTTUS:
No Yes

ACHING ALL OVER:
No Yes

ERECTION ISSUES:
No Yes

PREMATURE EJACUALTION:
No Yes

PORNOGRAPY ADDICTIONS:
No Yes

ANY OTHER:

QUESTIONS

HAVE YOU HAD A MASSAGE BEFORE?:
No Yes

BY:
Man Women Both

WHAT MASSAGE MOVEMENTS DO YOU LIKE?

DEEP PRESSURE:
No Yes

DEEP:
No Yes

MIXED MOVEMENTS:
No Yes

GENTLE:
No Yes

FEATHERING:
No Yes

WOULD YOU LIKE A FEMALE CHAPARONE TO BE PRESENT DURING THE TREATMENT?
No Yes

ARE THERE ANY PARTICULAR AREAS IN THE BODY THAT YOU NEED TO RECEIVE MORE ATTENTION?

NONE:
No Yes

HEAD:
No Yes

NECK:
No Yes

SHOULDERS:
No Yes

UPPER BACK:
No Yes

CHEST:
No Yes

BREAST:
No Yes

ARMS:
No Yes

LOWER ABDOMEN GROIN AREA:
No Yes

BUTTOCKS:
No Yes

LOWER ABDOMEN GROIN AREA:
No Yes

FEET:
No Yes

GENITALIA (YONI):
No Yes

MOUTH:
No Yes

FACE:
No Yes

ANY OTHER AREAS:

ARE THERE ANY AREAS IN THE BODY YOU WANT TO AVOID IN THE MASSAGE?

NONE:
No Yes

HEAD:
No Yes

NECK:
No Yes

SHOULDERS:
No Yes

UPPER BACK:
No Yes

CHEST:
No Yes

BREAST:
No Yes

ARMS:
No Yes

LOWER ABDOMEN GROIN AREA:
No Yes

BUTTOCKS:
No Yes

LOWER ABDOMEN GROIN AREA:
No Yes

FEET:
No Yes

GENITALIA (YONI):
No Yes

MOUTH:
No Yes

FACE:
No Yes

ANY OTHER AREAS: