Sexual Health History QuestionnaireSection IGeneral Health & Medical HistoryDo you have any chronic medical conditions? Do you have any chronic medical conditions?e.g., diabetes, hypertension, STIs, HIV, cardiovascular diseasesAre you currently taking any medications, including hormonal therapy, pre-exposure prophylaxis (PrEP), or antibiotics? Are you currently taking any medications, including hormonal therapy, pre-exposure prophylaxis (PrEP), or antibiotics?Have you had any surgeries or medical procedures related to sexual or reproductive health? Have you had any surgeries or medical procedures related to sexual or reproductive health?Section IISexual HistoryHave you been sexually active in the past 12 months? Have you been sexually active in the past 12 months?How many sexual partners have you had in the last 12 months? How many sexual partners have you had in the last 12 months?Section IIIProtection & Contraceptive UseDo you use condoms or other barrier methods? Do you use condoms or other barrier methods?If so, how often?Do you use any form of birth control? Do you use any form of birth control?Pill, IUD, implant, injection, patch, ring, etc.Have you ever had unprotected sex or experienced contraceptive failure? Have you ever had unprotected sex or experienced contraceptive failure?Section IVSTI & HIV ScreeningHave you ever been tested for STIs, including HIV? Have you ever been tested for STIs, including HIV? If so, when was your last test?Have you ever tested positive for an STI? Have you ever tested positive for an STI?If yes, was it treated?Do you experience any symptoms such as pain, discharge, itching, sores, or unusual bleeding? Do you experience any symptoms such as pain, discharge, itching, sores, or unusual bleeding?Have you received the HPV vaccine? Have you received the HPV vaccine?Section VPrEP & HIV PreventionAre you aware of HIV prevention options such as PrEP or post-exposure prophylaxis (PEP)? Are you aware of HIV prevention options such as PrEP or post-exposure prophylaxis (PEP)?Are you currently on PrEP for HIV prevention? Are you currently on PrEP for HIV prevention?Have you discussed HIV risk reduction with a healthcare provider? Have you discussed HIV risk reduction with a healthcare provider?Section VISexual Function & Well-beingDo you experience pain during sex? Do you experience pain during sex?Do you have concerns about libido (low/high sex drive)? Do you have concerns about libido (low/high sex drive)?Do you experience difficulties with arousal, orgasm, or performance? Do you experience difficulties with arousal, orgasm, or performance?Do you feel satisfied with your sexual relationships? Do you feel satisfied with your sexual relationships?Section VIIMental & Emotional Aspects of SexualityHow do you feel about your body and sexual confidence? How do you feel about your body and sexual confidence?Have you ever experienced trauma or unwanted sexual experiences? Have you ever experienced trauma or unwanted sexual experiences?Do you have concerns about sexual or relationship satisfaction? Do you have concerns about sexual or relationship satisfaction?Do you feel safe discussing your sexual health with partners and/or healthcare providers? Do you feel safe discussing your sexual health with partners and/or healthcare providers?Section VIIILifestyle & Social FactorsDo you use alcohol, tobacco, or drugs in relation to sex? Do you use alcohol, tobacco, or drugs in relation to sex?Do you feel comfortable communicating about consent and boundaries with partners? Do you feel comfortable communicating about consent and boundaries with partners?Do cultural, religious, or personal beliefs impact your sexual choices? Do cultural, religious, or personal beliefs impact your sexual choices?Section IXReproductive Health & Family Planning (If applicable)Are you trying to conceive, or do you plan to in the future? Are you trying to conceive, or do you plan to in the future?Have you had any past pregnancies, miscarriages, or abortions? Have you had any past pregnancies, miscarriages, or abortions?Do you experience menstrual irregularities, severe cramps, or other reproductive concerns? Do you experience menstrual irregularities, severe cramps, or other reproductive concerns?Section XAdditional ConcernsDo you have any questions or concerns regarding sexual health, function, or relationships? Do you have any questions or concerns regarding sexual health, function, or relationships?Would you like resources on sexual health education, counselling, or community support? Would you like resources on sexual health education, counselling, or community support?Is there anything else you would like us to know about your health or concerns? Is there anything else you would like us to know about your health or concerns?
Do you have any chronic medical conditions?
e.g., diabetes, hypertension, STIs, HIV, cardiovascular diseases
Are you currently taking any medications, including hormonal therapy, pre-exposure prophylaxis (PrEP), or antibiotics?
Have you had any surgeries or medical procedures related to sexual or reproductive health?
Have you been sexually active in the past 12 months?
How many sexual partners have you had in the last 12 months?
Do you use condoms or other barrier methods?
If so, how often?
Do you use any form of birth control?
Pill, IUD, implant, injection, patch, ring, etc.
Have you ever had unprotected sex or experienced contraceptive failure?
Have you ever been tested for STIs, including HIV?
If so, when was your last test?
Have you ever tested positive for an STI?
If yes, was it treated?
Do you experience any symptoms such as pain, discharge, itching, sores, or unusual bleeding?
Have you received the HPV vaccine?
Are you aware of HIV prevention options such as PrEP or post-exposure prophylaxis (PEP)?
Are you currently on PrEP for HIV prevention?
Have you discussed HIV risk reduction with a healthcare provider?
Do you experience pain during sex?
Do you have concerns about libido (low/high sex drive)?
Do you experience difficulties with arousal, orgasm, or performance?
Do you feel satisfied with your sexual relationships?
How do you feel about your body and sexual confidence?
Have you ever experienced trauma or unwanted sexual experiences?
Do you have concerns about sexual or relationship satisfaction?
Do you feel safe discussing your sexual health with partners and/or healthcare providers?
Do you use alcohol, tobacco, or drugs in relation to sex?
Do you feel comfortable communicating about consent and boundaries with partners?
Do cultural, religious, or personal beliefs impact your sexual choices?
Are you trying to conceive, or do you plan to in the future?
Have you had any past pregnancies, miscarriages, or abortions?
Do you experience menstrual irregularities, severe cramps, or other reproductive concerns?
Do you have any questions or concerns regarding sexual health, function, or relationships?
Would you like resources on sexual health education, counselling, or community support?
Is there anything else you would like us to know about your health or concerns?
