Sexual Health Wellness Check-in
Confidential self-assessment to support your sexual health and overall well-being.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Age
*
How would you describe your current sexual health?
*
Excellent
Good
Fair
Poor
Prefer not to say
In the past month, have you experienced any of the following? (Select all that apply)
*
Discomfort or pain
Unusual discharge
Sores or rashes
Itching or irritation
None of the above
Other (please specify)
How often do you have routine sexual health screenings (e.g., check-ups, STI testing)?
*
Every 3-6 months
Once a year
Less than once a year
Never
Please indicate your level of agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel comfortable discussing sexual health with my healthcare provider.
1
2
3
4
5
I practice safe behaviors to protect my sexual health.
6
7
8
9
10
I am satisfied with my current level of sexual health knowledge.
11
12
13
14
15
How would you rate your overall emotional well-being in relation to your sexual health?
*
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Are you currently experiencing any of the following concerns? (Select all that apply)
Stress or anxiety related to sexual health
Concerns about relationships or intimacy
Questions about contraception or protection
None of the above
Other (please specify)
Is there anything else you would like to share regarding your sexual health or wellness?
Submit Check-in
Should be Empty: