The Dr. Susan Block Institute

for the erotic arts & sciences

8306 Wilshire Blvd. Suite 1047 Beverly Hills, Ca. 90211 213.749.1330

Director: Susan Marilyn Block, Ph.D.

Patient Questionnaire

Please take your time to answer the following questions. Answers to essay questions can be as brief or detailed as you like. You may skip entire questions, if you wish. However, the more details you can provide, the better your experiences with The Dr. Susan Block Institute will be.

You do not have to be a patient with the Institute to fill out this questionnaire. The questionnaire is also the basis for a survey that the Institute is conducting on people’s sexual experiences and fantasies. Therefore, we encourage all types of people to fill it out, whether you seek sex therapy or not. After we have received about 3000 completed questionnaires, the information will be processed by the Institute. The results of the survey will be published on the Institute website at drsusanblock.com.