Form F
Sexual History Questionnaire
These are very personal questions. The answers help us to determine your risk level for getting infections or HIV. Some may not apply to your lifestyle, but we must ask.
Name ______DOB___/___/___
When (if ever) have you: (If yes, please explain.)
Had sex when you were drunk or high on drugs? □ Yes □No ______
Had sex with a male that has had sex with other men? □ Yes □No ______
Given or received money or drugs for sex? □ Yes □No ______
Had a partner who used injection drugs? □ Yes □No ______
Have you used injection drugs? □ Yes □No ______
Had a partner who tested positive for HIV? □ Yes □No ______
Had a tattoo or body piercing? □ Yes □No ______
To help us identify your risk level, please answer the following:
How old were you the first time you had sex? ______
When was your most recent sexual encounter? ______
How many people have you had sex with in the past 30 days? ______
What is your overall condom use? □ Always □ Most of the time □ Sometimes □ Rarely □ Never
How many people have you had sex with in your lifetime? ______
Have your partners had sex with other people? ______How do you know this?______
Have you ever been forced or pressured to have sex? ____ Age ____ Was it reported? ____ Counseling?______
Do you have sex with: □ Men □ Women □Both □ Other ______
In order to offer you the best medical service, please check the box of the sex you were assigned at birth.
□ Male □ Female □ Other ______
With what gender do you currently identify? □ Male □ Female □ Other ______
Have you ever been involved with a pregnancy before? □ Yes □ No
If yes, what happened? ______
______
We need your help to know where to look for infection. In the past, have you:
Had vaginal sex? □ Yes □No When? ______
Given oral sex? □ Yes □No When? ______
Received oral sex? □ Yes □No When? ______
Received anal sex? □ Yes □No When? ______
Given anal sex? □ Yes □No When? ______
Contraception/Protection against disease:
What is the status of your current relationship? ______
How do you feel after you have sex? ______
How at risk do you think you are for having a STD? ______
Comments:______