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
 | Are you on any medications which can impact on our play? |
| What are those medications? |
| What are they used for? |
| How do you feel they can impact on our play? |
| If you don't know how they can impact on our play do you have someone you can ask? |
Section 2: Conditions and diseases
| Do you have any medical problems which can impact on play? |
| How do those problems affect your every day life? |
| What are symptoms of a critical flare up of your disease? |
| If a flare up of this problem should happen how should I deal with it and what can I do to help you? |
| Are you willing to work out a plan to deal with any flare ups that may occur while we are playing? |
| If we decide we need further information on your disease do you have someone you can ask for help? |
Section 3: Past Surgeries:
| Have you had any surgeries that might impact on play? |
| If so how might that occur? |
| If we need further information do you have someone you can ask for help? |
Section 4: Notes on Medications and Diseases
| N-SAIDs examples Motrin, Naprosen, Aspirin, Aleve, Ibuprofen, Vioxx, Celebrex these can cause a person to bruise quicker and with less force then normal. |
| Anti-histamines examples Benadryl, Hismanal, Atarax, Actifed, and Seldane. These can cause blood pressure changes and changes in equalibrium. |
| Any Cardiac (heart) medications. Can change the blood pressure. |
| 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
| This tool is meant as a quick way to foster discussion between partners, it is in no way meant to replace discussion. |
| This tool is strictly medical in nature and the coverage of psychological issues should go hand in hand with any negotiations for play. |
| 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 DragonflyCopyright September 3, 2001
