Welcome to PlayDr.com

All Patients are requested to complete this form prior to scheduling their examination.
  Your information will be kept in strict confidence.

Demographics (** are required fields)

**Name:   **Date of Birth: / /
**Contact Email:

City/State of Residence:  ,

Weight: (in pounds):      Height (in inches): 
Are you interested in a real-time medical fantasy examination?  Yes No
When are you available for examination : /
Hair Color: Eye Color:
Measurements: Bust Cup - Waist - Hips Dress Size:

Do you have any Body Piercings or Tattoos?:
Have you ever been pregnant? If "YES" -How many times:
How many imes have you given birth? Date of Last Birth: /
Do you have problems with Hemorrhoids?
Pubic Hair: Would you like the Doctor to Trim/Shave your pubic hair?:
Does your current sexual partner know of your interests?
How does s/he respond?:
Do you have any bi-sexual tendencies?
If "Yes", describe them as they may relate to a medical fantasy or scenario.
How would you dress to visit the Doctor?

Have you ever participated in medical fantasy play before?
If "Yes" please describe your past experience(s). If "No" then please describe your interests (as well as they have been identified.)

Have you become aroused during an actual medical examination?
If "Yes, was the practitioner Male or Female?:
Please describe the experience below:

If 'NO', and this is something that you would like to experience,
please describe what you would like to occur:

Have you ever had a rectal examination?
If 'YES' did the Doctor use a rectal speculum, anoscope, or proctoscope?
Are you willing to have the Doctor watch you provide a urine sample?
Are your nipples sensitive to touch? If 'YES', please indicate what experiences you enjoy:
No Preference Stroking Pinching Pulling Biting Nipple Clamps Other
Have you ever been spanked? If 'YES', please describe the experience below:

If 'NO', would you like to be spanked? If 'YES', please indicate the items you would enjoy being spanked with: Hand Hair Brush Paddle Belt Other
What is the level of pain that you desire or can tolerate?
Do you feel the need to be disciplined? If 'YES', please expalin why and what you may feel is effective discipline:

Do you feel you need to be restrained?
If 'yes', please explain and specifically include the use of wrist and/or ankle restraints, blindfolds, gags, etc:

How frequently do you masturbate?
What do you do that is particularly arousing?

Have you ever used a vibrator/dildo? If 'YES', please describe the experience:

Do you use the vibrator: externally, internally, rectally
Do you enjoy oral sex? If 'YES', to what extent: giving receiving both
If 'NO', why not:

Have you ever participated in anal sex?
If 'YES', to what extent: giving receiving fingers sex toy(s)
If 'NO', to what extent are you curious or interested?
Have you ever inserted your finger into a man's anus/rectum?
If you have done this, or want to do this, please explain:

Within the past several years (3-5), have you had your temperature taken rectally?
If 'YES', please describe the experience; if 'NO', but you woul like to have your temperature taken rectally, please indicate this preference:

Within the past several years (3-5), have you been given an enema?
If 'YES', please describe the experience; if 'NO', but you woul like to be given an enema, please indicate this preference. What type of enema equipment was/would be used?

Are you able to provide a witnessed urine sample?
Do you want to be catheterized (urinary catheter)?
During an examination, is it possible that you would become aroused to the extent that you would request the Doctor to perform a sexual act with you?
If 'YES', what would you request:
If 'NO', how would you relieve your arousal?

What was the date of your last GYN exam: M or F practitioner:
What was the date of your last period?
How regular are they?
Do you use:
* If you have had any gynecological surgery, please explain:

Is there anything else that you would like the Doctor to know before the examination commences?

Do you have any curiosity in "reciprocating". in other words, would you like to be the nurse/doctor?

If 'YES', what are your curiosities/interests?

Thank you for your cooperation. Your answers will help the Doctor to more fully complete his assessment.

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