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."
|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
|8.||For females: Do you
have any problems with sexual functioning, for example, getting aroused,
becoming lubricated, experiencing pain during sexual activity, or problems
|9.||Is there anything else that I
need to know about your sexuality in order to provide you with good
|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)
Immunization Action Coalition1573
Paul MN 55104
E-mail: firstname.lastname@example.org Web: http://www.immunize.org/
Tel: (651) 647-9009Fax: (651) 647-9131
This page was updated on May 17, 2004