(25) Underline applicable fundamental or original instinct: Fellatio (active buccal). Passive buccal. Masturbation of other. Mutual onanism. Paedicatio (anal),
indicating whether subject is active or passive, or both. Cunnilingus (corresponding to active fellatio in the male). Tribadism (corresponding to masturbation of other in the male).
(26) Approximate age when instinct first manifested itself in the feelings..... years. In actions..... years.
(27) Secondary or acquired methods of coitus............
(28) Is subject a psychical hermaphrodite (attracted toward both sexes)..........
(29) Does coitus stimulate any erogenous center (i.e., afford a pleasurable titillation of any portion of the body) or is the satisfaction entirely or almost entirely mental
(30) sStateof health day following coitus
(31) If a male, does coitus induce an emission..... If so, is sensation pleasurable or horrifying.............
(32) Is there love or adoration for the associate, or is the latter used merely to secure the stimulation of the subject's erogenous center
(33) Upper and lower age limits of individuals that attract, with indication of subject’s own age at the different periods
(34) Any quality or apparel (such as plumpness, military uniform) that constitutes a special attraction
(35) If a physical male, is he undersized..... If female, unusually large..... Muscles vigorous or feeble.........
(36) Is there a striking contrast between the real and apparent age.....
(37) Any peculiarity about the hair system, particularly the facial
(38) If a physical male, any tendency to wear the hair several inches long
(39) Describe any anatomical approach toward the psychical sex (e.g., milk glands in a male)...............
(40) Ever desired to wear apparel of psychical sex..... Ever worn such apparel since childhood. ........
(41) If a physical male, fondness for loud or fancy apparel..... If female, for plain apparel..............
(42) Ever arrested or imprisoned for following instincts of psychical sex..... If so, aggregate number of months or years mprisoned
(43) Please note, any other significant data as to particular homosexualist on separate sheets.
GENERAL QUERIES:
(44) Approximate number of homosexualists — positively known as such—have you encountered in your life-time: Passive inverts.... Active pederasts.... Male psychical hermaphrodites.... Physically female homosexualists....
(45) How many additional individuals have been under your suspicion: Passive inverts.... Active pederasts.... Male psychical hermaphrodites.... Physically female homosexualists....
(46) The author of "utobiography of an Androgyne” estimates, roughly, passive inverts as 1 out of 300 physical males. Please give your estimate: Passive inverts, 1 out of....males. Active pederasts, 1 out of....males. Male psychical hermaphrodites, 1 out of....males. Female psychical hermaphrodites, 1 out of....females. Other physically female homosexualists, 1 out of....females. (In query 46, only adults are to be considered.)
NAME AND ADDRESS OF PHYSICIAN SUBMITTING SCHEDULE. THIS INFORMATION WILL BE CONSIDERED CONFIDENTIAL, AND IS ESSENTIAL.
Name
Street and number
Post-office
State
Date
