Recovery Nation - Initial Sexual Health Assessment

SEXUAL HEALTH ASSESSMENT
(Part 2 of the Comprehensive Assessment for Coaching)

This assessment is to gather baseline information from those participating in Professional Coaching. However, if you are not participating in professional coaching, but would like your assessment evaluated, we will do so--as time and energy permit--in the order that it was received. You must supply a password to retrieve the results.

General Information:

First Name:
User Name:
E-mail address:
Password: (to receive results)
Briefly describe your reason for seeking assessment (e.g. Part of Professional Coaching Process, curiosity, advice of counselor, etc.):

Begin Assessment (Part 1 of 12)

1. What is your current sexual preference?

a. Describe "other":

2. At what age did you become aware of your current sexual preference?

1-96 Enter age of awareness; 0-If always preferred; 97-If Unknown

3. Are you satisfied with your current sexual preference?

1-Yes 2-No 3-Unsure

4. How many sexual/romantic partners have you had:

a. In the past 30 days?

b. In the past year?

c. In your lifetime?

5. Of the sexual partners you have had, how often have you maintained 'safe-sex' practices?

1-Always 2-Usually 3-Seldom 4-Never 5-Not Applicable

6. Are you engaging in sexual behavior that is having (could have) a significantly impact on your life?

1-Yes 2-No 3-Unsure

7. Document your experiences with the following:

For all behaviors exhibited below, click on the corresponding "follow-up" link

Behavior	Age of 1st Experience (1-96; 0 if never)	Past 90 Days (Times)	Past 30 Days (Hours)	Follow-up Questions
A) Masturbation				Follow-up
B) Pornography				Follow-up
C) Promiscuity				Follow-up
D) Transvestism				Follow-up
E) Fetishism				Follow-up
F) Erotic Fantasy				Follow-up
G) Prostitution				Follow-up
H) Exhibitionism				Follow-up
I) Voyeurism				Follow-up
J) Frotteurism				Follow-up
K)Ecouterism				Follow-up
L)Erotographomania				Follow-up
M) Sexual Thievery				Follow-up
N) Sadism				Follow-up
O) Masochism				Follow-up
P) Beastiality				Follow-up
Q) Stalking				Follow-up
R) Molestation				Follow-up
S) Incest				Follow-up
T) Rape				Follow-up
U) Other				Follow-up

8. For the behaviors listed in the chart above, enter the letter (A-T) for each behavior you have exhibited for longer than one year:

9. Have you ever been treated for sexually compulsive behavior?

1-Yes 2-No

If Yes:

a) How many times?
b) How long ago was the last treatment?
c) How long did that treatment last?
d) What was the treatment setting?
1-Inpatient 2-Outpatient (monitored) 3-Outpatient (self-monitored)
e) Did you successfully complete the program?
1-Yes 2-No 3-Unsure/Not Applicable

10. Has a friend, employer, family member, etc. ever suggested counseling to help you deal with a matter directly or indirectly related to your sexual/romantic behavior?

1-Yes 2-No

11. Using the scale below, rate the negative impact that your sexual and/or romantic behaviors have had on your: (1-No effect 2-Slight 3-Moderate 4-Considerable 5-Extreme)

Family (1-5)Friends (1-5)Co-workers (1-5)

Career (1-5)

Finances (1-5)

Romantic Relationships (1-5)

Self-esteem (1-5)

Stress level (1-5)

Time management (1-5)

Hobbies (1-5)

Follow-up Questions (to be answered if behavior listed above)

A) Masturbation

1. On average, how many times per day do you masturbate?
2. How often do you masturbate in public places?
3. How often do you masturbate while driving (or other dangerous environments)?
4. How often do you masturbate at work?
5. Do you believe that masturbating is interfering with your ability to manage intimate relationships with others?
6. How many times have you attempted Autoerotic Asphyxiation?
7. How often do you masturbate to the point of exhaustion?
8. How often do you feel guilty after masturbating?

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B) Pornography