Name : Isabella Swan Date : June 3, 2010

For each item mark yes or no to indicate prior experience

"Yes" or "No"

After indicating experience mark with a number 0-4 to indicate interest in that idea

0 indicates - a hard limit, something the sub has an aversion to.

1 indicates - no desire to do this, but does not have a particular aversion to it. Something the sub would consider doing however to please a dominant.

2 indicates - that he or she would probably like the activity, could be something that is an enjoyable fantasy, but that the sub is not sure will translate into an enjoyable real life activity. Also could be something the sub wants but is embarrassed to admit.

3 indicates - that this activity is something that he or she would like to do, perhaps a reoccurring fantasy and often something that the sub has done in the past and enjoyed.

4 indicates - the sub finds this activity a wild turn on and has a particular fetish or preoccupation with it.

Activity -May - June

Abrasion - No – 0 - No – 0

Age play (not pedophilia) - No - 3 - No – 3

Anal Plugs - No - 3 - A - Yes - 4

Anal Sex- Yes - 4 - Yes – 4

Animal roles- No – 0- No – 0

Arm and Leg Sleeves - No - 2- No – 2

Asphyxiation - No - 0 - No -0

Ball Gag - No - 2 - No – 3

Ball Stretching - No – 0 - No - 0

Beat - hard - Yes - 0 - Yes – 0

Beating - soft - Yes – 0 - Yes – 0

Being Blindfolded - Yes - 3 - Yes – 4

Being Gagged - No – 2 - No – 3

Being Serviced (sex) - Yes - 3 - Yes – 4

Bestiality - No - 0 - No – 0

Biting - Yes - 1 - Yes – 2

Bondage Heavy - No - 2 - Yes – 4

Bondage Light - No - 3 - Yes – 4

Boot worship - No - 2 - No – 2

Branding - No – 0 - No – 0

Breast Bondage - No - 3- Yes – 4

Breast Fucking - Yes - 3 - Yes – 4

Breast Whipping - No - 2 - Yes – 4

Brown Showers - No – 0 - No – 0

Cages - Yes – 0 - Yes – 0

Caning – English - No - 2 - No – 1

Caning – Sensational - No - 2 - No – 1

Catheterization - No – 0 - No – 0

Chains - No - 2 - No – 2

Chastity Device - No - 3 - No – 3

Chauffeuring - No – 0 - No – 0

Choking- Yes – 0 - Yes – 0

Chores- Yes - 3 - Yes – 3

Chosen Clothing for - No - 2 - Yes – 4

Chosen Food for - No - 2 - Yes – 3

Clothespins - No - 3 - No – 3

Cock Worship - No - 2 - No – 3

Collars - No - 3 - Yes – 4

Corsets - Yes - 4 - Yes – 4

Cuffs - No - 3 - Yes – 4

Cutting - No – 0 - No - 0

Dilation- No – 0- No – 0

Double Penetration- Yes - 4- Yes – 4

Ear Plugs - No - 2 - No – 2

Electricity - No – 0 - No – 0

Enemas - Yes - 3 - Yes – 3

Examinations - No - 1 - Yes – 3

Exhibitionism - No - 4 - No – 4

Eye contact restrictions - No - 2 - No – 2

Face Slapping - Yes – 0 - Yes – 0

Fantasy Gang Rape - No – 0 - No – 0

Fantasy Rape - No – 0 - No – 0

Figging - No - 1 - No – 3

Fisting - No – 0 - No – 0

Flogging - No - 2 - Yes – 3

Follow Orders - No - 3 - Yes – 4

Foot worship - No - 1 - No – 1

Forced Dressing - No - 2 - Yes – 3

Forced Feminization - No – 0 - No – 0

Forced Homosexuality - No – 0 - No – 0

Forced Masturbation - No - 3 - Yes – 4

Forced Nudity - No - 3 - Yes – 4

Forced Servitude - No - 1 - Yes – 3

Genital sex - Yes - 3 - Yes – 4

Given Away - No – 0 - No – 0

Golden showers - No – 0 - No – 0

Group Play - No - 1 - No – 1

Hair Pulling - Yes - 2 - Yes – 2

Hair Brushes - No - 2 - Yes – 3

Harnessing - No – 0 - No – 0

High Heel Worship - No - 1 - No – 1

Homage with Tongue - No - 1 - No – 3

Hoods - No – 0 - No – 0

Hot Wax Dripping - No - 3 - Yes – 4

Hot Wax Hair Removal - Yes - 3 - Yes – 3

Housework - Yes - 2 - Yes – 2

Human Puppy - No – 0 - No – 0

Humiliation in Private - Yes - 1 - Yes – 3

Humiliation in Public - Yes – 0 - Yes –1

Ice Cubes- Yes - 2 - Yes – 3

Infantilism - No – 0 - No – 0

Initiation Rites - No - 2 - No – 2

Injections - No – 0 - No – 0

Interrogations - No - 2 - Yes – 3

Intricate Rope Bondage - No - 3 - Yes – 4

Kidnapping - No – 0 - No – 0

Kneeling - No - 3 - Yes – 4

Leather Restraints - No - 3 - Yes – 4

Lecturing - No - 2 - Yes – 2

Mantra and meditation - No - 3 - Yes – 3

Massage - getting- No - 3 - No – 3

Massage – giving- Yes - 3 - Yes – 3

Medical Scenes- No - 1 - No – 1

Model for Erotic Pictures- No - 3 - No – 4

Mouth Bits- No – 0 - No – 0

Name Change - No - 1 - No – 1

Nipple Clamps - No - 3 - Yes – 3

Nipple Weights - No - 2 - No – 2

Oral – getting - Yes - 3 - Yes – 4

Oral – giving to opposite sex- Yes - 3 - Yes – 4

Oral – giving same sex- No – 0- No – 0

Orgasm Control- No - 2 - Yes – 3

Orgasm Denial- No - 2- Yes – 2

Outdoor Scenes - No - 2 - No – 3

Over the Knee Spanking - No - 2 - Yes – 4

Paddling - No - 2 - No – 3

Personality Modification - No - 1 - No – 1

Phone Sex - No - 3 - No – 3

Piercing - Permanente - No - 3 - No – 3

Piercing – Temporary - No - 3 - Yes – 4

Prison Scenes - No – 0 - No – 0

Prostitution – real or fantasy - No – 0 - No – 0

Pussy Whipping - No - 1 - Yes – 3

Pussy Worship- No – 0 - No – 0

Ridding Crops- No - 3 - Yes – 4

Rimming- No - 1 - No -1

Rituals- No - 2 - Yes – 4

Religious Scenes- No – 0 - No – 0

Rope Bondage- No - 3 - Yes – 4

Rubber/Latex Clothing - No - 2 - No – 2

Saran Wrapping - No - 1 - No – 1

Scarification - No – 0 - No – 0

Scratching – getting- No - 1 - No- 1

Scratching – giving - No - 1 - No -1

Sensory Deprivation - No - 2 - No – 3

Serving as Maid - No - 2 - No – 2

Serving as Pony - No – 0 - No – 0

Serving as Furniture/Art - No – 1 (art) - No – 3 ( Art )

Serving as Toilet - No - 0 - No – 0

Serving Orally - Yes - 3 - Yes - 4

Serving other Doms (supervised) - No – 0 - No – 0

Sexual Depravation - No - 1 - No – 3

Shaving - Yes - 3 - Yes – 3

Sleep Deprivation - No -1 - No – 1

Slutty Clothing - No - 3 - No – 3

Spandex Clothing - No - 3 - No – 3

Spanking - No - 3 - Yes – 4

Speculums - Yes - 0 - Yes – 0

Speech Restrictions (what & when) - No - 2 - Yes – 4

Spreader Bars- No - 3 - Yes – 4

Stable (serving w/other subs) - No – 0 - No – 0

Standing in Corner - No - 3 - Yes – 3

Stocks - No- 1 - No – 1

Strait Jackets- No - 1 - No – 1

Strap-on-Dildos - No - 0 - No – 0

Strapping - No - 1 - No – 2

Suspension - No - 1 - Yes – 3

Swapping- No – 0 - No – 0

Swinging -No - 0 - No – 0

Tape Gags - Yes - 1 - Yes – 1

Tattooing - No - 3 - Yes – 3

Teasing - No - 2 - Yes – 3

Thumb Cuffs - No - 2 - No – 2

Tickling - No - 2 - Yes – 2

Triple Penetration - No - 2 - No – 2

Uniforms - No - 2 - No – 2

Verbal Humiliation - No - 2 - Yes – 3

Video Taped Scenes - No - 3 - Yes – 4

Voyeurism - No - 3 - Yes – 4

Whipping - Yes – 0 - Yes – 0

Wooden Paddles- No - 2 - No – 3

Wrestling - No – 0 - No – 0

Any allergies that the Dom(me) should be aware? (if yes, describe:)

No

Any medical conditions? (if yes, give details:)

Yes - C3 & C4 vertebra fused -

Do not have full range f motion in my neck

Do not have 100% use of right arm

15 pound weight limit

Any specific subject not described in this list that the Dom(me) should be concern with? (if yes describe:)

No

Any fears real or imagined that would cause you extreme anxiety (if yes describe)

Extreme Claustrophobia

Dark Places

Closed Rooms with no windows

Loud Sudden Noises