Intake Form

Training in Men’s Sexual Cultivating Sexual Practices

If you are human, leave this field blank.

1. CONTACT INFORMATION

Full Name

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone

2. PERSONAL INFORMATION

Reproductive System is-

Male

Female

Birthday xx/xx/xxxx

Height and Weight

Current State of Health

Excellent

Good

Fair

Poor

What health issues or concerns are you currently dealing with?

What major surgeries have you had (please include year)?

What medications are you currently taking (include viagra, Cialis, etc.)

When was your last test for STDS (Sexually Transmitted Diiseases)

What current Recreational drugs do you use? (include Plant Medicines)

Upload a clear picture of your tongue to determine your Constitution (Traditional Chinese Medicine)

In Traditional Chinese Medicine (TCM), looking at a picture of your tongue is one of the fastest ways to read what’s happening inside your body. (To learn more, go to: download PDF at:

For Men to answer-

Check any of these Issues you have experienced?

Premature Ejaculation

Erectile Dysfunction

Enlarged Prostate

Prostate Cancer

Others

RELATIONSHIP/FAMILY

What is your current Relationship Status

Married

Divorced

Single

What is your Relationship Preference?

Monogamy

Poly/Open

Communal

It Depends

What is your Sexual Preference

Straight

Bisexual

Gay

Prefer Not to Answer

Do you have children? (if so, how many).

SEXUAL ENERGY CLTIVATION TRAININGS & PRACTICES.

What are your Goals and Motivations in wanting to learn Sexual Cultivation Practices?

List all prior teachers, trainings, books, audios, videos, workshops, classes, related to sexual practices you have taken.