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Brief Sex History Questionnaire
    


 
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This questionnaire may be used as part of the review of systems with patients. The clinician might begin, "I need to ask a few short questions about your sexual health in order to be thorough in providing your medical care."
 
Patient name:
Birthdate:
Chart number:
________________________________
________________________________
________________________________
   
1. Are you sexually active? __________________________
   
2. If so, when was the last time you engaged in sexual activity? __________________________
   
3. If you are sexually active, are you sexual with men, women, or both?
men          women          both
   
4. How many people have you been sexual with in the past year?
0       1       2-3       4-10       more than 10
   
5. What, if anything, do you do to protect yourself from getting a sexually transmitted disease, (including HIV)? Have you ever had a sexually transmitted disease?

 

 

   
6. If applicable: What do you do to protect yourself or your partner from unplanned pregnancy?

 

 

   
7. For males: Do you have any problems with sexual functioning; for example, getting aroused, getting or maintaining an erection, or problems with ejaculation or orgasm?

 

 

   
8. For females: Do you have any problems with sexual functioning, for example, getting aroused, becoming lubricated, experiencing pain during sexual activity, or problems with orgasm?

 

 

   
9. Is there anything else that I need to know about your sexuality in order to provide you with good medical care?

 

 

Adapted with permission from the Program in Human Sexuality, Department of Family Practice and Community Health, University of Minnesota Medical School, 11/25/03. Thanks also to Harold S. Levine of Levine & Co., NY, NY.

Item #P4401 (1/04)

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This page was updated on May 17, 2004