Patient History & Pre Screen Application for Suzanne SxySadist AKA Naughty nurse Nasty!

Part 1 General Patient Information

Patient's email address? ex:Receptionist@NurseNasty.net<mandatory>

Patient's first name

Patient's location (city/state)

Phone/Pager (if pos.):  

Patient's Age:  

Do you have major medical and / or life insurance? I may not take insurance but you may need it! <grin, just teasing>

Gender:  
Male Female Cross dresser

Marital Status:  
Married Single but attached Single and free Divorced Widowed Poly-amorous

Name of next of kin, or who to contact in case of an emergency. <grin, just teasing again>

Sexual Orientation:  
Straight Bi-curious Bi-sexual Gay/lesbian

Health related issues I need to be aware of that may impact our session: (please list past or recent chronic conditions, injuries, disabilities or phobias) Also list any especially sensitive areas or medications you are taking that I should be aware of:

Please inform me of any emotional issues that you feel may cause a potential trigger or bad reaction: (rape, incest, child abuse, race concerns) or anything that I should be aware of that is a potential problem for you in a scene emotionally. 

Part 2 Medical Scene Basics:

Describe your kinky medical experience thus far, if any:

If experienced how many years have you been exploring this for, or how long have you been interested in it?

What, if any, marks are acceptable to you & for how long?

What do you feel is the most important element of a kinky medical scene?

Which choice best describes your interest?
Sensation play Psychological play Both are equally important I just want to serve

Are there any particular activities you feel you would like to challenge or explore? 

Please briefly describe your ideal but realistic medical scene. I want at least a few sentences in this field or don't bother continuing.

Do you have any particular fetishes? (rubber, leather, feet, boots, scents, etc) Please share some details: 

Do you feel "release" is absolutely essential to a good kinky medical session ; if so why? (Please note: I do NOT jerk off patients nor do I guarantee that you will be permitted to manually "finish"  in my facility).

Medical Role Play

How important is the patient / nurse / doctor role play to your ideal scene? 
Very important
Somewhat important
Not at all important

How important is the realism of the medical procedures to you?

Do you have any thoughts on the patient / nurse role play you would like to share?

What do you picture Nurse Nasty wearing? (be careful, this is a set up question! I don't promise to wear what you ask for and I turn away a lot of people based on inappropriate answers here!)

Please describe at least 3 qualities that you envision when you think of your ideal nasty nurse. 

Part 3 Medical Play Activities Section

Now we get to see what things you want to experience in a medical session with me. Please choose an interest level beside each activity and then check off any items below that interest you. Also feel free to put a comment, concern or question in the box below any of the categories. Please be as thorough as possible! I like variety A LOT!

Anal dilation & dildo play: No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a ot Have exp & love it

Dildo / butt plug
Fingers
Fisting
Prostate Exam
Forced Oral on strap-on
Rape / Gang Bang fantasies
Strap-on
Vibration
Other:

Want to briefly describe fantasy scene or share any thoughts?:

Asphyxiaphilia & respiration play): No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Lightly restrictive
Moderate restriction
Heavily restrictive
Carotid Pressure
Devices that Restrict
Hoods /gags
Re-breathers ("Bagging" slow O2 deprivation)
Smothering
Suffocation
Other:

Want to briefly describe fantasy scene or share any thoughts?:

Electrical Testing & Neural Stimulation: No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Internal PSE Unit
Tens Unit 
Violet Wand
Stun Gun
Cattle Prod
Other:

Want to briefly describe fantasy scene or share any thoughts?:

Hydro-Therapy & Catheters: No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Klismaphilia (enema)
Colonic (deep enema)
Sensual enemas
Punishment enemas
Bladder irrigation
Urethral Catheters
Urolagnia (watersports aka golden showers)
Other:

Want to briefly describe a fantasy scene or share some thoughts?:

Humiliation & Psychology Department:  No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Mild level
Moderate level
Heavy level
Being spit on
Collar & Leash
Crawling
Exhibitionism
Face slapping
Feminization
Hair Pulling
Kneeling 
Public Display
Used as an object (table, foot rest, ashtray etc) 
Verbal Degradation
Forced to consume own cum, piss etc
Other:

Want to briefly describe fantasy scene or share any thoughts?:

Medical Restraint No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Lightly restrictive
Moderate restriction
Heavily restrictive
Body Bag
Caging
Chains
Leather Bonds
Long periods of bondage
Mummification
Medical cuffs
Neck Brace
Rope Bondage
Straight Jacket
Suspension

Other:

Want to briefly describe a fantasy scene or share any thoughts?:

Sensory Deprivation: No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Blindfolds
Ear Plugs / headphones
Gags
Gas Masks
Hoods
Light & Sound Therapy
Vacuum bed

Other:

Want to briefly describe fantasy scene or share any thoughts?:

Urology & Gynecology Dept (Geni-torture aka CBT & Pussy torture): No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Light activity
Moderate activity
Heavy activity
Abrasion
Castration Fantasies
Chastity Devices
Clamps / Clothespins
Genital Bondage
Infibulation
Saline Infusion
Pressure
Urethral Dilation & Sounding
Weights
Other:

Want to briefly describe fantasy scene or share any thoughts?:

Nipple & Breast Exam:  No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Light activity
Moderate activity
Heavy activity
Abrasion
Breast / nipple exam
Clamps / Clothespins
Nibbling / Biting
Stretching
Suction cupping
Weights
Other: 

Want to briefly describe fantasy scene or share any thoughts?:

Temperature Play: No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Alcohol lighting
Branding 
Cauterization
Candle wax
Cigarette / incense torture
Ice & other cold goodies
Other:

Want to briefly describe fantasy scene or share any thoughts?:

Piercing / Suturing/ Cutting:  No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Cuttings (Acucullophallia)
Beading (body adornment)
Blood Play
Injections (sterile saline)
Lacing (tying needles for bondage)
Suturing
Surgery (mock)
Surgical Stapling
Temporary Piercing (just below the skin)
Testicle Piercing
Have permanent piercings (list)
Other:

Want to briefly describe fantasy scene or share any thoughts?:

Tactile Stimulation & Sensation Play:  No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Cupping (suction of the skin)
Feathers
Fur
Light /soft flogging
Massage / relaxing body work
Mild abrasion /scratching
Tickle torture
Other:

Want to briefly describe fantasy scene or share any thoughts?:

Part 4 Miscellaneous Non-Medical Specific Activities

Age Play / Infantilism: No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Diaper Fantasies
Depilation (shaving) 
Parent /child fantasies
Student /teacher fantasies
How old do wish to be?
Other:

Want to briefly describe fantasy scene or share some thoughts?:

Feminization / Cross dressing / Transvestitism: No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Have clothes I can bring (describe)
Have no clothes need to borrow(list sizes)
Public shopping trips
Maid service /training
Sissy slut training
Other:

Want to briefly describe fantasy scene or share any thoughts?:

Foot & leg worship: No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Would like some in the scene, but none main focus
Wants a moderate amount in the scene
My main interest in the scene
Altocalciphilia (love of high heels)
Bare feet
Boots
Enjoys kissing /licking feet /legs 
Gives a good foot massage
Stocking feet  
Pantyhose
Trampling
Willing to learn to give pedicure
Other:

Want to briefly describe fantasy scene or share any thoughts?:

Percussion & Palpation: No exp & not interested at all No exp & somewhat curious No exp & very curious Have exp & dislike it Have exp & like somewhat Have exp & like it a lot Have exp & love it

Light activity
Moderate activity
Heavy activity
Spanking
Floggers
Whips (single tails)
Paddles
OTK (over the knee)
Canes
Crops
Other: 

Sensations that I enjoy or think that I might enjoy most:
Thuddy/Thumpy
Stingy/Sharp
Combinations or variety of sensations

Materials I enjoy or think I would enjoy: 
Deerskin
Leather
Nylon
Rattan
Rubber
Synthetics
Wood
Other: 
Corporal play comments or fantasy:

Part 5 Final Section

Referral and Web site commentary: How did you hear about me? Where did you find my web link etc? (Domme board, banner link other?) 

Any comments or suggestions about the web site? Ease of navigation, ambiance, loading speed, pic quality etc? 

Photos: I like to take new photos for my web site. I of course would never do so without the patient's knowledge and consent, and even with permission I usually take measure's to protect the identity by covering the face and any identifiable marks with a hood etc. if s/he wishes to remain anonymous. Please let me know where you stand with the idea of taking pics: 

Mailing List: I occasionally send out newsletters to to my mailing list that includes info on special I may be offerings as well as my travel schedule. I send this mailing on average of 4 times a year so it isn't like you will be swamped with unsolicited letters from me but if you are interested in this mailing please be sure to join by using the form under the navigation menu.

I also am planning to start an invite list for private parties at my home, would you like an invite once we get to know each other?  

Please read this last bit and initial the bottom. 
"I understand that the answers to this questionnaire are to be used only to plan a BDSM session. My limits will be respected and I may stop the scene at any time I wish. I understand that Nurse Nasty is a skilled professional dominatrix and that care and caution is taken to insure my safety, but I acknowledge that there is inherent risk to BDSM play. I further understand that there will be NO sex of any kind, NO illegal activities permitted, and NO nudity on the part of the Mistress." 
Initials:

Finally, did thinking about and picturing all of these things while filling out the form excite you just a little? (Any last words?)

Ok great and thank you for your efforts! Once you hit "Submit the completed form will be automatically mailed to me at Receptionist@NurseNasty.net

I should respond to you within 48 hours with more information or further instructions. If however I do not it may mean I am away for a few days. I answer all email that I receive one way or the other. If you do not hear from me within 72 hours you may wish to send a follow up email in case your email was lost in cyber space.

Best Wishes!! Nurse Nasty