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Before Scene: Interview

Author: Norische

Filed in: negotiation, play, scene, checklist


Name: __________________________________________________________________

Age ____________ Gender___________ Sexual Orientation ____________________

How Top wishes to be addressed. ____________________________________________

I am mainly into : (D/s, Sadism, Masochism, Bondage, Fetish, Power Exchange)

Safety Codes:

Red: Stop

Yellow: I\'m ok but slower/less/careful

Green: I\'m fine, go on, more


Visible bruises/cuts/marks must be avoided (Y/N):

Heath Issues: (Hemophilia, Allergies, Asthma, Breathing Problems, Blood Sugar Issues, Circulation)

Allergies and how they affect you.

Medications: Have you taken any medications, including Aspirin within the last 4 - 6 hours.
Please include any Prescription medication you are on.
Current Medications, dose, and what the medication is prescribed for.

Medical Conditions (give as much detail as possible)

Surgeries (give as much detail as possible)

Eye Glasses (Y/N)

Contacts (Y/N)

Any current medical injuries or problems...(sinuses, pulled muscle. Ect…)

No hit zone if any:

Phobias or Fears:

Other Remarks: (safety issues, triggers, etc)

I want aftercare (Y/N)

I like to talk after a scene (Y/N)

I want extensive verbal communication during a scene (Y/N)

I want music during the scene (Y/N)

Sexual Contact (Y/N)


Fully Clothed
Shirt Off
Underwear Only
Fetish Clothing


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