Disclaimer:  This document has been modified from it’s original.  The creator is unkown and similar checklists appear on many BDSM sites.  This checklist has been modified for those wishing to distinguish between fantasy and real life scenes.  It also provides a place for the person filling it out to clarify whether or not they’ve experienced a particular activity as either a sub or dom.  While many specific items are for submissives, they can just as easily be answered by the dominant partner.

Submissive / Dominant / Switch Activity Checklist

Willingness on a scale of 0-5

0 (zero) indicates you have utterly no desire to do that activity and don't like doing it. (In fact, may loath it.  It would turn you off and you would want this to be a hard limit.)  

If you indicate a 1, this means you don't want to do or like to do this activity, but wouldn't object if it was asked of you.   You would be willing to do it to please your partner if it they really wanted it. (Sometimes called a "soft limit").

If you indicate a 2, this means you are willing to do this activity, but it has no special appeal for you.   

If you indicate a 3, this means you usually like doing this activity, at least on an irregular or occasional basis.   

If you indicate a 4, this means you like doing this activity, and would like to experience it on a regular basis.  

If you indicate a 5, this means the activity is a wild turn-on for you, and you would like it as often as possible.

0 means no, this is a hard limit.
5 means go for it.  Yes, please, I want some more.
Y is yes, you’ve experienced it
N is no, you haven’t

Category	Desire for this in fantasy play	Desire for this in real life play	Experienced this activity as a sub

( Y or N)	Did this activity as a dom to a sub
( Y or N)	
Abrasion 					
Age play 					
Anal sex					
Anal plugs (small)					
Anal plugs (large)					
Anal plug 
(public, under clothes)					
Animal roles 					
Arm & leg sleeves (arm binders)					
Asphyxiation					
Auctioned for charity 					
Auctioned for real 					
Bathroom use control					
Bestiality  					
Beating (soft)					
Beating (Medium)					
Beating (hard)					
Blindfolds					
Being serviced (sexual)					
Being bitten					
Breast/chest bondage					
Breath control					
Boot worship 					
Bondage (light)					
Bondage (heavy)					
Bondage (multi-day) 					
Bondage
(public, under clothing)					
Breast whipping					
Breast spanking					
Brown showers (scat)					
Cages (locked inside of)					
Caning					
Catheterization					
CD Cum Depravation hours					
CD Cum Depravation days					
Cells/Closets (locked inside of) 					
Chastity belts					
Boot worship					
Choking					
Clothespins 					
Cock worship					
Collars (worn in private) 					
Collars (worn in public) 					
Competitions (with other Subs) 					
Corsets (wearing)					
Costumes (wearing)					
Cuffs (leather)					
Cuffs (metal)					
Cutting					
Dilation					
Double penetration					
Electricity					
Enemas					
Enforced chastity 					
Examinations (as pet) 					
Examinations (like doctor) 					
Exercise (forced/required) 					
Exhibitionism (friends) 					
Exhibitionism (strangers) 					
Eye contact restrictions					
Face slapping					
Fantasy abandonment 					
Fantasy rape					
Fantasy gang-rape					
Fisting (anal)					
Fisting (vaginal)					
Following orders					
Foot worship					
Forced dressing					
Forced homosexuality 					
Forced masturbation 					
Forced nudity (private) 					
Forced nudity (around others)					
Forced servitude					
Full head hoods					
Gags (cloth)					
Gags (rubber)					
Gags (tape)					
Gates of Hell (male)					
Genital sex					
Given away to another Dom (temp)supervised / nearby					
Given away to another Dom (perm)					
Golden showers					
Hairbrush spankings					
Hair pulling					
Hand jobs (giving)					
Hand jobs (receiving)					
Harems (serving w/other subs)					
Harnessing (leather)					
Harnessing (rope)					
Having food chosen for you					
Having clothing chosen for you					
Head (giving fellatio) 					
Head (receiving fellatio)					
High heel worship					
Homage with tongue (non-sexual)					
Hot oils (on genitals)					
Hot waxing 					
Housework (doing) 					
Human puppy dog 					
Humiliation (private) 					
Humiliation (public) 					
Hypnotism					
Ice cubes					
Including others					
Infantilism					
Initiation rites					
Injections					
Intricate (Japanese) rope bondage					
Interrogations					
Kidnapping					
Kneeling					
Leather clothing					
Licking (non-sexual)					
Manacles & Irons					
Manicures (giving)					
Massage (giving)					
Massage (receiving)					
Medical scenes 					
Modeling for erotic photos					
Mouth bits					
Mummification					
Nipple clamps					
Nipple weights					
Oral/anal play (rimming)					
Over-the-knee spanking					
Orgasm denial					
Orgasm control					
Outdoor scenes					
Outdoor sex					
Phone sex (serving Dom)					
Phone sex (serving Dom's friends) 					
Piercing (temporary, play-pierce)  					
Piercing (permanent)					
Prison scenes					
Pony slave					
Public exposure					
Puppy play 					
Kitty play 					
Pussy/cock whipping					
Pussy worship					
Riding the "horse" (crotch tort.) 					
Rituals					
Religious scenes					
Restrictive rules on behavior					
Rubber/latex clothing					
Rope body harness					
Saran wrapping					
Scratching - getting 					
Scratching - giving					
Sensory deprivation					
Serving					
Serving as art					
Serving as ashtray					
Serving as furniture					
Serving as a maid					
Serving as toilet					
Serving as waitress/waiter					
Serving orally (sexual)					
Serving other doms (supervised)					
Serving other doms (unsupervised) 					
Sexual deprivation (short term)					
Sexual deprivation (long term)					
Shaving (body hair)					
Shaving (head hair)					
Sleep deprivation					
Sleep sacks					
Slutty clothing (private)					
Slutty clothing (public)					
Spanking					
Spandex clothing					
Speech restrictions (when, what)					
Speculums (Anal)					
Speculums (vaginal)					
Spreader bars					
Standing in corner					
Stocks					
Straight jackets					
Strap-on-dildos (sucking on)					
Strap-on-dildos (penetrated by)					
Strap-on-dildos (wearing)					
Strapping (full body beating)					
Suspension (upright)					
Suspension (inverted)					
Suspension (horizontal)					
Supplying new partners for Dom					
Swallowing semen					
Swallowing urine					
Swapping (with one other couple)					
Swinging (multiple couples)					
Tattooing					
Teasing					
Tickling					
Triple penetration					
Uniforms					
Vaginal dildo					
Verbal humiliation					
Vibrator on genitals					
Voyeurism (watching others)					
Voyeurism (your Dom w/others)					
Video (watching others)					
Video (recordings of you)					
Water torture					
Wearing symbolic jewelry					
Whipping					
Wooden paddles					
Wrestling