1. PEOPLE IN SCENE:	

The sub agrees to address the dominant by the following title(s):		

2. OOPS:	
Does everybody involved understand that there is some risk of accident, miscommunication, misperception, and/or unintentional injury?	Yes	
	
No	

	
Does everybody involved agree to discuss any mishaps in a constructive and non-blaming manner?	Yes	
	
No	

	
 
3. LIMITS:	
Submissive's limits: Any problems with the submissive's	
heart:	
Yes	
	
No	

	lungs:	
Yes	
	
No	

	kidneys:	
Yes	
	
No	

	
neck/back:	
Yes	
	
No	

	bones/joints:	
Yes	
	
No	

	liver:    	
Yes	
	
No	

	
nervous system:	
Yes	
	
No	

	mental:	
Yes	
	
No	

		
Explanation:	
Is the submissive wearing contact lenses?	Yes	
	
No	

	
Does the submissive have a history of	
seizures:	
Yes	
	
No	

	dizzy spells:	
Yes	
	
No	

	blood pressure:	
Yes	
	
No	

	
diabetes:	
Yes	
	
No	

	fainting:	
Yes	
	
No	

	asthma:    	
Yes	
	
No	

	
hyperventilation attacks	
Yes	
	
No	

		
Explanation:	
Describe any phobias:	
Submissive's other medical conditions:	
Any surgical implants (breast, face, etc.)?	Yes	
	
No	

	
Is the submissive taking aspirin?	Yes	
	
No	

	
Is the submissive taking ibuprofin, Aleve, or other anti-inflammatory drugs?	Yes	
	
No	

	
Is the submissive taking antihistamines?	Yes	
	
No	

	
Other medications the submissive is taking:	
Allergies:	
In case of emergency notify:		

4. SEX:	
Does any participant believe they might have a sexually transmitted disease?	Yes	
	
No	

	
Explanation:	
Does any participant believe they might have herpes? Note: herpes takes many forms and generally only the genital form is of concern.	Yes	
	
No	

	
Explanation:	
Have participants been tested for HIV?	Yes	
	
No	

	
Has any participant tested positive?	Yes	
	
No	

	
Explanation:	

which of the following sexual acts are acceptable:	
Masturbation: dominant to submissive 	submissive	Yes	
	
No	

	
Masturbation: submissive to dominant	Yes	
	
No	

	
self-masturbation by submissive	Yes	
	
No	

	
self-masturbation by dominant	Yes	
	
No	

	
Oral: dominant to submissive	Yes	
	
No	

	
Oral: submissive to dominant	Yes	
	
No	

	
Analingus: dominant to submissive	Yes	
	
No	

	
Analingus: submissive to dominant	Yes	
	
No	

	
Vaginal fisting: 	dominant to submissive	Yes	
	
No	

	
Vaginal fisting: 	submissive to dominant	Yes	
	
No	

	
Anal fisting: 	dominant to submissive	Yes	
	
No	

	
Anal fisting: 	submissive to dominant	Yes	
	
No	

	
Vaginal intercourse: 	dominant to submissive	Yes	
	
No	

	
Vaginal intercourse: 	submissive to dominant	Yes	
	
No	

	
Anal intercourse: 	dominant to submissive	Yes	
	
No	

	
Anal intercourse: 	submissive to dominant	Yes	
	
No	

	
Is swallowing semen acceptable?	Yes	
	
No	

	
Is any participant menstruating?	Yes	
	
No	

	
Will sex toys such as vibrators, dildoes, butt plugs, etc. be used?	Yes	
	
No	

	
What safe sex / birth control devices/methods will be used?

5. BONDAGE:	
The submissive agrees to allow (only) the following types of bondage...		
hands in front:	Yes	
	
No	

	
hands behind back:	Yes	
	
No	

	
ankles:	Yes	
	
No	

	
knees:	Yes	
	
No	

	
elbows:	Yes	
	
No	

	
wrists to ankles (hog-tie):	Yes	
	
No	

	
spreader bars:	Yes	
	
No	

	
tied to chair:	Yes	
	
No	

	
use of blindfold:	Yes	
	
No	

	
use of gag:	Yes	
	
No	

	
use of hood:	Yes	
	
No	

	
use of rope:	Yes	
	
No	

	
use of tape:	Yes	
	
No	

	
use of leather cuffs:	Yes	
	
No	

	
use of handcuffs/metal restraints:	Yes	
	
No	

	
suspension:	Yes	
	
No	

	
mummification with plastic wrap, body bag, or similar technique:	Yes	
	
No	

	
Any past bad experiences by either person with bondage, gags, blindfolds, and/or hoods?	Yes	
	
No	

	
Explanation:	

6. PAIN:	
Submissive's general attitude toward receiving pain:	
Quantity of pain the submissive wants to receive:	
Dominant's general attitude toward giving pain:	
Quantity of pain the Dominant wants to give:	
The following types of pain are acceptable...	
spanking	Yes	
	
No	

	
paddling	Yes	
	
No	

	
flogging	Yes	
	
No	

	
caning	Yes	
	
No	

	
face slaps	Yes	
	
No	

	
biting	Yes	
	
No	

	
nipple clamps	Yes	
	
No	

	
genital clamps	Yes	
	
No	

	
clamps elsewhere	Yes	
	
No	

	
Locations:	
hot creams	Yes	
	
No	

	
ice	Yes	
	
No	

	
hot wax	Yes	
	
No	

	
tickling	Yes	
	
No	

	
Other types/methods of pain:
7. MARKS:	
Is it acceptable to the submissive if the play leaves marks?	Yes	
	
No	

	
Visible while wearing street clothes?	Yes	
	
No	

	
Visible while wearing a bathing suit?	Yes	
	
No	

	
Is it acceptable to the submissive if the play draws small amounts of blood?	Yes	
	
No	

	
How easy or difficult has it been to mark the submissive in the past?	

8. EROTIC HUMILIATION	
The submissive agrees to accept being referred to by the following terms:
	
The submissive agrees to the following forms of erotic humiliation	
"verbal abuse":	Yes	
	
No	

	
enemas:	Yes	
	
No	

	
forced exhibitionism:	Yes	
	
No	

	
spitting:	Yes	
	
No	

	
water sports:	Yes	
	
No	

	
scat games:	Yes	
	
No	

	
face slapping/hair pulling:	Yes	
	
No	

	
Other:	
Any prior really good or really bad experiences in these areas?	Yes	
	
No	

	
Explanation:	

9. SAFEWORDS AND MEANINGS	

 
10. AFTERCARE	
What aftercare does the bottom prefer?
	
What aftercare does the top prefer?

11. FOLLOW-UP	
Who will initiate contacts?	After the session:	

The next day:	

A week later:	

In the event of a crisis:	

	
Acceptable methods	Email	
Yes	
	
No	

	

Text	
Yes	
	
No	

	

Phone	
Yes	
	
No	

	

In Person	
Yes	
	
No	

	

Other: