(After each valid answer ask "Who would make you guilty for that")

Name: ______________________________

Date: ______________________________

01. Has somebody embarrassed you sexually? _____

02. Has sex with someone been boring to you? _____

03. Has someone persuaded you to engage in a sexual activity when you didn't want to? _____

04. Have you ever felt degraded about a sexual experience? _____

05. Has somebody seduced you? _____

06. Has somebody used sex with you to obtain favors? _____

07. Has somebody led you on sexually? _____

08. Has somebody withheld sex from you? _____

09. Has somebody invalidated you sexually? _____

10. Have you ever been heartbroken? _____

11. Have you ever bragged about sexual experiences? _____

12. Has somebody lied to you about their sexual past? _____

13. Has somebody used you sexually? _____

14. Have you ever been raped? _____

15. Has somebody degraded you sexually? _____

16. Has somebody drugged you for sexual purposes? _____

17. Has somebody flirted with you when you didn't want them to? _____

18. Has somebody been unfaithful to you? _____

19. Have you ever daydreamed about anyone sexually? _____

20. Has somebody told you that sex was bad? _____

21. Has somebody pretended to enjoy sex with you? _____

22. Was somebody mean to you as a child? _____

23. Did anyone perform sexual actions with you as a child? _____

24. Were your parents mean to you? _____

25. Did you have any sexual withholds from your parents? _____

26. Were your brothers and sisters mean to you? _____

27. Has somebody rejected you sexually? _____

28. Have children ever bothered or disturbed you? _____

29. Did someone try to abort you? _____

30. Did someone want an abortion when you didn't? _____

31. Were you ever neglected as a child? _____

32. Were you ever abused as a child? _____

33. Did you ever hate your parents? _____

34. Has a sexual partner been cruel to you? _____

35. Was anyone cruel to you as a child? _____

36. Was another child favored over you? _____

37. Were you spoiled as a child? _____

38. Did you feel that a brother or sister was spoiled? _____

39. Were you mishandled as a child? _____

40. As a child did you ever destroy your toys to get even? _____

41. As a child did you ever destroy another's possessions out of revenge? _____

42. Have you been forced sexually? _____

43. Have you been implanted with sexual compulsions? _____

44. Have you been implanted with sexual inhibitions? _____

45. Have you been implanted that sex was evil? _____

46. Have you been implanted with sexual pictures? _____

47. Have you been given any false data about sex? _____

48. Do you feel the effect of anything about sex? _____

49. Do you have any opinions about sex that you find hard to express? _____

50. Is there anything concerning sex that you have a withhold about? _____