1 what is the reason for your visit check all that

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Our Sexuality
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Chapter 15 / Exercise 02
Our Sexuality
Baur/Crooks
Expert Verified
1. What is the reason for your visit? (Check all that apply.) __ You think you could be at risk for an STI. __You think you could be at risk for HIV/AIDS. __Other: ______________ _ 2. If you have symptoms, please check all that apply: __ Bleeding __ Pain __ Rash __ Warts __ Itching Problems with urination __ Other: ___________ _ 3. Have you had sexual interactions with anyone in the last 6 months? __Yes No With how many people? 2 3 4 5 6 7 8 9 1 0 more than l O 4. How many people have you had sexual interactions with in your lifetime? 0 2 3 4 5 1 0 1 5 25 30 50 75 more than 1 00 5. When with new or non-steady partners, do you use a condom or barrier? __Always __ Most of the time __ Sometimes __ Rarely Never 6. Have you had sexual interactions with: __A man __ A woman Both __Other 7. Check all that apply: __ Oral sex __ Vaginal sex __Anal sex: __ Top (lnsertive) __ Bottom (Receptive) Both 8. Please list any medication(s) you are currently taking: ________ _ 9. Please list any allergies to medication(s): ____________ _ 10. Have you ever exchanged drugs or money for sex? __Yes No 11. Have you had sex with someone you know injects drugs? __Yes No 12. Have you ever used a needle to inject drugs? __Yes No 13. Have you had sexual interactions with someone you know has HIV/AIDS? __Yes No 14. Have you used meth, speed, crank, crystal, cocaine, or crack in the last year? __ Yes No 15. Do you smoke cigarettes? __ Yes __ No 16. Have you ever been in jail or prison? __ Yes No 17. Do you have any tattoos? __ Yes __ No
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Our Sexuality
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Chapter 15 / Exercise 02
Our Sexuality
Baur/Crooks
Expert Verified
18. Have you had the hepatitis B vaccine? __Yes No 19. How many HIV/AIDS tests have you had before today? __ 20. Have you ever been diagnosed with an STI? (Check all that apply below and indicate when.) __ Have symptoms __ Have no symptoms -STI testing/screening only __ Referred by another doctor or clinic __ Discharge _______ _ __Sores/Blisters _______ _ _ _ Chlamydia _ _ _ _ _ _ _ _ _ _Gonorrhea _ _ _ _ _ _ _ _ _ _ Genital Warts _ _ _ _ _ _ _ _ _ H erpes _ _ _ _ _ _ _ _ _ _ _ _ Syphilis _ _ _ _ _ _ _ _ _ _Trichomonas (trich) _ _ _ _ _ HIV _________ _ __ Other: __________ _ __ Never been diagnosed with an STI 21. Do your female sex partners use birth control? __Yes No 22. If so, what birth control method(s) are used: __________ _ Not sure 23. Would you like more information on contraceptive methods? __ Yes No Source: Questionnaire adapted from: Marin County Department of Health and Human Services, STD Risk Self- Assessment Questionnaire 2010. It might feel a little personal and invasive to fill out a questionnaire such as this, but it is important that you have this information readily available, particularly for health care providers so they can work with you in making important sexual health decisions. • Create a positive peer culture-Have a peer group that supports and uses condoms and contraception, and promotes STI protection. • Keep a positive attitude-Value partners who consistently use condoms, have a posi- tive attitude toward condoms and contraception, and know the benefits of condom and contraception use. • Consistently use effective protection-People who have previously used condoms or contraception often have greater motivation, intent, and confidence in using effec- tive and protective means of contraception. • Be informed-Individuals who are older at the time of first voluntary sexual inter- course are more likely to use condoms and contraception and to use them correctly. WHAT'S ON YOUR MIND? Q: I just recently found out that I have an ST! and I informed my partner, but my partner is refusing to get tested. What do I do?
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182 HUMAN SEXUALITY

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