These questions are intended to be only personally meditated upon for you own personal reflection and are intended to be completely private.

In reviewing each of these questions, guard against exaggerating and also guard against denying.  The questions are intended to be thought provoking. A starting point where you can quietly gauge what you want to improve in with in your walk of purity and holiness. Answering the questions honestly will help you address any hungers or longings, concerning any unmet needs within yours or your heart. If you do not struggle with any heart lust or out of control behavior, it is vitally important that you too ponder each question so that you have clarity of the journey you are undertaking.

For married men, or young men living with others, if your wife, parents or roommates see this survey it could stir curiosity.  Therefore, to keep these questions private, I suggest you do NOT give you answers out in any way.  Some questions may not apply to you, so circle NA.  (Not applicable)

Are you in agreement with the bible that lust and all sex outside of marriage is sin?           Yes    No         

  1. What was the primary source of your sex education?   A) Parents     B) Church      C) School           D) Self-taught   E) Peers F) Media   G) Other  ____________                                                                                   
  2. Are you currently sexually active with someone other than your spouse?   (within this past year?)    Yes    No
  3. If so, do you practice safe sex (condoms)?   Yes    No
  4. Have you ever fathered a child outside of marriage?    Yes    No
  5. Have you ever fathered a child that was aborted?   Yes    No
  6. If yes to question 6, did you give consent?  NA    Yes    No       
  7. Did you ever have or do you now have a sexually transmitted disease (STD) or an                                       sexually transmitted infection (STI?)  Yes    No
  8.  Have you ever been with a prostitute?  Yes    No
  9. In the last three months have you gone on the Internet to porn sites or sex-based chat rooms?    Yes    No (A) In the past month?     (B) In the past week?   _______________________                  
  10. Have you ever used your cell phone for “sexting?” or to view porn?    Yes    No
  11. In the last three months, have you visited adult bookstores or strip clubs, anyplace  where sexual activity is promoted?    Yes     No                                                                                                                                                                                                                                                      
  12. Since becoming a Christian, have you ever paid for sex, bought porn, or viewed porn on a computer?  Yes    No
  13. At this present time do you own any porn (videos- magazines-books-CD’s–or have any porn stored on your computer)?     Yes    No
  14. Do you currently have a “filter” or “accountability program” installed on your computer  preventing you from viewing porn?    Yes    No
  15. If, Yes, does it:

                              Effectively stop you from looking at porn? _______

                             Slow you down in your efforts to view porn?_______

                             Cause you to find new ways to view porn? _______

                             Challenge you to find ways around it?  _______

                              NA  _______

  1. In the past four weeks what would you say is the closest number of times you have masturbated? A) Once in the past month    B) Once every other week  C) Once a week  D) Twice a week               E) Three times a week F) Four times a week  G) Five times a week H) Six times a week I) Daily                                                 J) Multiple times a day  K) NA  ________
  2. Is lust an on-going issue in your life? A) Never      B) Seldom      C) Often      D) Intense  _________    
  3. Concerning any struggle with the issue of sexuality in your life (lust or behavior) do you struggle with shame (various degrees of self-hatred)?  A) Never B) Seldom  C) Often  D) Intense  E) NA _______
  4. Concerning any struggle with sexual issues (lust or behavior), do you experience guilt?
  5. A) Never B) Seldom      C) Often      D) Intense      E) NA  ______
  6. Does lust or any out-of-control sexual behavior seem to hit you in cycles?    (Bingeing)     

         If so, How Often?     # __________ Weekly   #  ______  monthly    #        ______  a year? 

        Or is it something that cannot be measured by “time” but more accurately by your “mood swings?”  

        eg feeling lonely, feeling angry, feeling rejected?  A) Never   B) Seldom   C) Often   D) NA  _______                                          

  1. If married and you struggle sexually, is your wife aware of your struggle?
  2. A) Aware B) Somewhat Aware      C) Unaware      D) NA  ________
  3. Do you consider yourself a sex addict?   Yes      No
  4. Are you currently in an accountability relationship concerning this topic with another man or men Yes      No
  5. If all your thoughts and secrets were known, including your sexual ones, do you think the pastors                  and elders of this church would reject you?   Yes     No
  6. Do you think the pastor and elders at this church would be a help, a source of further shame/rejection or are unequipped to help you if you shared your sexual struggles with them?                                    A) Help B) Source of Shame/Rejection    C) Unequipped  _______   
  7. Are you willing to be transparent and trust one or two men within your home church with your sexual issues?   Yes     No
  8. Are you aware of the laws in you State or Country concerning sexual active which are illegal?       Yes   No
  9. Circle five of the following words that are the most prominent issues in your life.       

    Anger     Rage     Hatred     Bitterness     Pride    Other Addictions   Jealousy     Judging Others         Marriage  Loneliness     Unforgiveness     Rejection   Guilt   Self-hatred     Self-pity     Gossip     Lying     Stealing Prayerlessness   Shame    Being deceitful     Laziness     Prejudice   Workaholism     DepressionPerformance Orientation     Perfectionism    Generational Sins    Other -________________

31. Have you been totally honest with yourself in pondering these questions?    Yes    No

 

 

Copyright 2010

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