Massage Questionnaire

What area(s) are you having pain or discomfort?
(check as many as apply)

Neck

Shoulder

Upper Back

Lower Back (sacral area)

Pelvis

Thighs

Calves

Feet

Are there any activities that you find particularly uncomfortable?
(check as many as apply)

If you're having discomfort during or after sex where is the pain primarily located: (check as many as apply)

Testicles

Penis

Anal area

Groin in general

Please describe the size of your penis when erect:

Have women ever complained that sex is too painful or completely unfeeling for them because of your penis size?

Yes very painful

Yes they cannot feel my penis

No I've had no complaints

What would be the girth or circumference of your penis when it's erect?

0" - 3"

4" - 6"

7" - 9"

Do you find that your penis size could be causing some of your lower back problems?

Yes

No

How often are you having sex?

0 - 3 times per week

4 - 6 times per week

7 - 10 times per week

Several times daily

Would you say that your problem has increased or decreased your ability to have sex?

Increased

Decreased

Are you adverse to being nude for your massage?

Yes

No