Medical Safety Questionnaire

These Questions are designed with safety in mind, safety of both the submissive and the Dominant. Each question should be answered fully and answers elaborated on as needed.

Section 1: Medications
bullet Are you on any medications which can impact on our play?
bullet What are those medications?
bullet What are they used for?
bullet How do you feel they can impact on our play?
bullet If you don't know how they can impact on our play do you have someone you can ask?

Section 2: Conditions and diseases
bullet Do you have any medical problems which can impact on play?
bullet How do those problems affect your every day life?
bullet What are symptoms of a critical flare up of your disease?
bullet If a flare up of this problem should happen how should I deal with it and what can I do to help you?
bullet Are you willing to work out a plan to deal with any flare ups that may occur while we are playing?
bullet If we decide we need further information on your disease do you have someone you can ask for help?

Section 3: Past Surgeries:
bullet Have you had any surgeries that might impact on play?
bullet If so how might that occur?
bullet If we need further information do you have someone you can ask for help?

Section 4: Notes on Medications and Diseases
bullet N-SAIDs examples Motrin, Naprosen, Aspirin, Aleve, Ibuprofen, Vioxx, Celebrex these can cause a person to bruise quicker and with less force then normal.
bullet Anti-histamines examples Benadryl, Hismanal, Atarax, Actifed, and Seldane. These can cause blood pressure changes and changes in equalibrium.
bullet Any Cardiac (heart) medications. Can change the blood pressure.
bullet Diabetes, Heart Disease and Asthma are three of the most common diseases to be aware of and need in-depth discussion as to what can occur and plans made to deal with these diseases in relation to a scene.

Section 5: Disclaimer
bullet This tool is meant as a quick way to foster discussion between partners, it is in no way meant to replace discussion.
bullet This tool is strictly medical in nature and the coverage of psychological issues should go hand in hand with any negotiations for play.
bullet This tool is in no way meant to be a comprehensive examination of all the diseases one may encounter if you have any questions about any unusual diseases seek someone who can assist you in planning play time to be safe and fun.

Be Well All and Play Safe.

Madam Dragonfly

Copyright September 3, 2001
madam_dragonfly@webramp.net

This checklist came out of a discussion I led for the Albany, New York Kink Community. The need seemed genuine and I thought I would give it a try. If you have any comments, suggestions, ideas, feed back or questions please send them to me Madam Dragonfly madam_dragonfly@webramp.net
and I will work them into this list. Please feel free to repost as you wish as long as you credit it to me and my site.