Sexual History Worksheet
On a separate pad of paper or on an Excel spreadsheet, create a grid with 12 columns.
Column 1:
In as chronological order as possible, make a list of every individual with whom you’ve had any type of
inappropriate sexual encounter, whether voluntary or involuntary. (This includes touching private body
parts, oral sex, penetration of any kind, phone sex/sexting, etc.)
Column 2:
Indicate whether the experience was (A) voluntary or (B) involuntary on YOUR part.
Column 3:
Indicate whether the experience was (A) voluntary or (B) involuntary on the OTHER person’s part.
Column 4:
List YOUR age range from the start to the finish of this sexual experience (i.e. 16-18).
Column 5:
List the age range of the OTHER person from the start to the finish (i.e. 21-23).
Column 6:
Indicate where you met or what ROLE this person played in your life (i.e. friend, relative, babysitter,
neighbor, stranger, teacher, boss, spiritual leader, mentor, etc.)
Column 7:
In as few words as possible, was there something specific that drew you to this person? How did they fit
your “mental mold?” Was it a certain look? Something about their personality? Did they remind you of
someone? Make you feel a certain way?, etc.
Column 8:
Rate your PHYSICAL response to this experience on a scale from 0 to 10
(“0” = NO pleasure at all / “10” = enormous pleasure)
Column 9:
Rate your EMOTIONAL response to this experience on a scale from 0 to 10
(“0” = NO emotional connection felt / “10” = incredibly bonding and satisfying)
Column 10:
Were you expecting to gain something in particular from this experience/person? If so, what was the
perceived “payoff?”
Column 11:
Were your expectations met?
Column 12:
Make any special note that you need to in order to clarify the nature of this relationship.
(Copyright Shannon Ethridge Ministries. Please do not copy or distribute without prior permission.)