Relapse Analysis

Use this form to help you analyze your relapse; then use the results to help you avoid making the same mistake again.

  1. Where did you view the pornography?
    • Home
    • School
    • Store
    • Other (Explain)
  2. What medium did you use?
    • Print
    • Internet
    • Video
    • Television
    • Other (Explain)
  3. What were you doing just prior to viewing the pornography?
    • Working
    • Driving
    • Sleeping
    • Reading
    • Watching TV
    • Other (Explain)
  4. How were you feeling?
    • Anxious
    • Depressed
    • Bored
    • Stressed
    • Rejected
    • Hungry
    • Angry
    • Lonely
    • Tired
    • Other (Explain)
  5. What contributed most to your temptation to view pornography?
    • How you were feeling
    • What you were doing
    • Being alone
    • Other (Explain)
  6. How did you feel after viewing the pornography?
    • Relieved
    • Disappointed
    • Hopeless
    • Guilty
    • Other (Explain)
  7. Did you masturbate as a result of viewing the pornographic material?
    • Yes
    • No
  8. Did you anticipate this type of situation would tempt you?
    • Yes
    • No
  9. How often do you encounter situations like this one?
    • Daily
    • A few times a week
    • Once a week
    • A few times a month
    • Once a month
    • Other (Explain)
  10. What did you learn from this situation that will help you in the future?
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