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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." |
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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?
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| 6. | If applicable: What do
you do to protect yourself or your partner from unplanned pregnancy?
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| 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?
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| 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?
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| 9. | Is there anything else that I
need to know about your sexuality in order to provide you with good
medical care?
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| 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