(I found this online and it said it was public domain to be shared freely so feel free to use it yourself as well!) 

Yes = I have participated in this activity before

No = I have not participated in this activity before

The second answer should be your interest in engaging in that activity on a scale of 0 – 5, NO,?, +, ! or a combination.

0 = I have no interest/don’t like this, but would do it to please you.
1 = Not very interesting/don’t really enjoy this too much.
2 = This is OK,
3 = This is nice/fun/interesting
4 = I really enjoy/think I’ll enjoy this activity
5 = I LOVE THIS/CAN’T WAIT TO TRY THIS

NO = Hard limit. I will not participate in this activity at all, at this time.
 ? = Unfamiliar with this activity.
+ = I’m scared of this but would possibly like to explore it.
 ! = I’m embarrassed to admit I like this.

Examples:

Flogging: Yes/5 (Have done it before/LOVE IT!)
Cutting: No/+ (Have never tried/scared of this but might like to try it)
Golden Shower: No/5! (Have never done it/really exciting/embarrassed to admit it)
Fluffernutting: No/? (Have never done it/what the heck is it????)
Tickling: Yes/5+! (Have done this before/love it/scared of it/embarrassed I like it)

———————————————————————————————————————————————————————————————————-

OK Let’s get started!

Abrasion: No/?

Age Play: No/3

Anal Sex: Yes/5

Asphyxiation: Yes/4

Beating hard: Yes/4

Beating soft: Yes/2

Begging/Pleading: Yes/5

Being Blindfolded: Yes/3

Being Gagged: Yes/3

Bestiality: No/NO

Biting: Yes/5

Bondage (heavy): No/3

Bondage (light): Yes/4

Boot Worship: No/2

Branding: No/NO

Breast bondage: No/3

Breast Whipping: No/3

Brown Showers/Scat (feces play): No/NO

Caning: No/3

Catheterization: No/NO

Chauffeuring: No/?

Choking: Yes/4

Chosen Clothing for: No/0

Chosen Food For: No/0

Clothespins: No/2

Cock Worship: No/3

Collars (wearing): No/3

Corsets (wearing): No/1

Cutting: No/NO

Daddy Play: No/NO

Dilation: No/NO

Double Penetration: Yes/4

Electricity: No/1

Enemas: No/NO

Examinations (physical): No/2

Exhibitionism: No/0

Face Slapping: Yes/4

Fantasy Gang Rape: No/0

Fantasy Rape: Yes/3

Fisting: No/NO

Flogging (back): No/4

Flogging (butt): No/4

Following Orders: Yes/5

Foot Worship: No/2

Forced Dressing: No/0

Forced Homosexuality: No/2

Forced Masturbation: No/3

Forced Nudity: No/3

Forced Servitude: No/2

Full Head Hoods: No/0

Genital Sex: Yes/5

Given Away: No/NO

Golden Showers (piss play):  No/NO

Hair Pulling: Yes/5

Hairbrushes (spanking): No/4

Hand Jobs: Yes/4

Handcuffs (metal): Yes/5

Head (getting): Yes/5

Head (giving): Yes/4 

High Heel Worship: No/NO

Hot Waxing: Yes/2

Housework: Yes/1

Human Pony: No/NO

Human Puppy: No/NO

Humiliation In Private: Yes/2

Humiliation In Public: No/NO

Ice Cubes: NO/5

Including Others: No/2

Infantilism: No/NO

Injections: No/NO

Interrogations: No/NO

Intricate Rope Bondage: No/5

Kidnapping: No/1

Kneeling: Yes/4

Leather Restraints: No/4

Lecturing: No/0

Licking: Yes/3

Massage(getting): Yes/5

Massage(giving): Yes/4

Medical Scenes: No/0

Mommy Play: No/NO

Mouth Bits: No/2

Mummification(saran wrap etc): No/0

Nipple torment:(clamps etc.): Yes/3

Oral/Anal Play: Yes/ 3

Orgasm Control: No/5

Orgasm Denial: No/5

Over-the-Knee Spanking: Yes/5

Phone Sex: No/1

Piercing (perm): No/NO

Piercing (temp): No/NO

Pussy Whipping: Yes/3

Pussy Worship: No/NO

Religious Scenes: No/NO

Riding Crops: Yes/4

Scratching: Yes/4

Sensory Deprivation: Yes/4

Serving as Ashtray: No/NO

Serving as Furniture: No/0

Serving as Maid: No/0

Serving as Pony: No/NO

Serving Orally: No/??

Serving: No/3

Sex in Scene: No/5

Sexual Deprivation: No/3

Shaving: No/NO

Single Tail (light/sensual): No/?

Single Tail (moderate/heavy) No/?

Spanking: Yes/5

Speculums (vaginal): No/NO

Spreader Bars: No/5

Stocks: No/0

Straight Jacket: No/NO

Strap-on Dildos: No/0

Supplying Victims: No/????

Suspension (inverted): No/1

Suspension: No/2

Swapping: No/NO

Swinging: No/NO

Tape Gags: No/2

Tattooing: No/NO

Teasing: No/5

Tickling: No/NO

Triple Penetration: No/4

Uniforms: No/2

Verbal Humiliation: No/4

Videoed Scenes: No/NO

Voyeurism: No/1

Whipping (cat o’ nine tails etc.): No/3

Wrestling: Yes/4