Other 2 if you have symptoms please check all that

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Other:2.If you have symptoms, please check all that apply:BleedingPainRashWartsItchingProblems with urination Other:3.Have you had sexual interactions with anyone in the last 6 months? YesNo With how manypeople?12345678910more than 104.How many people have you had sexual interactions with in your lifetime?012345101525305075more than 1005.When with new or non-steady partners, do you use a condom or barrier?AlwaysMost of the timeSometimesRarelyNever6.Have you had sexual interactions with:A manA womanBoth Other7.Check all that apply:Oral sexVaginal sexAnal sex: Top (Insertive)Bottom (Receptive)Both8.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?YesNo11.Have you had sex with someone you know injects drugs?YesNo12.Have you ever used a needle to inject drugs?YesNo13.Have you had sexual interactions with someone you know has HIV/AIDS? YesNo14.Have you used meth, speed, crank, crystal, cocaine, or crack in the last year? YesNo15.Do you smoke cigarettes? YesNo16.Have you ever been in jail or prison? YesNo17.Do you have any tattoos? YesNoPage 18118.
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 symptomsHave no symptomsSTI testing/screening onlyReferred by another doctor or clinicDischargeSores/BlistersChlamydiaGonorrheaGenital WartsHerpesSyphilisTrichomonas (trich)HIVOther:Neverbeen diagnosed with an STI21.Do your female sex partners use birth control?YesNoNot sure22.If so, what birth control method(s) are used:23.Would you like more information on contraceptive methods?Yes NoSource: Questionnaire adapted from: Marin County Department of Health and Human Services, STD Risk Self-AssessmentQuestionnaire 2010.It might feel a little personal and invasive to fill out a questionnaire such as this, but it is important that youhave this information readily available, particularly for health care providers so they can work with you inmaking important sexual health decisions.
WHAT'S ON YOUR MIND?Q:I just recently found out that I have an STI and I informed my partner, but my partner is refusing to gettested. What do I do?

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Term
Spring
Professor
NoProfessor
Tags
Human Sexuality, Sexual intercourse, Human sexual behavior

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