Sexual History Questionnaire
Please answer the following questions honestly and to the best of your ability. Your responses are confidential and will help provide appropriate care and guidance.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Female
Male
Non-binary
Prefer not to say
Other
Relationship Status
*
Single
In a relationship
Married
Separated/Divorced
Widowed
Other
Have you ever been sexually active?
*
Yes
No
With how many sexual partners have you had sexual contact in your lifetime?
*
What is the gender of your sexual partner(s)?
*
Male
Female
Non-binary
Prefer not to say
Other
Which forms of contraception or protection do you use?
*
Condoms
Oral contraceptives
Intrauterine device (IUD)
Implant
Withdrawal
None
Other
Have you ever been diagnosed with a sexually transmitted infection (STI)?
*
Yes
No
Prefer not to say
If yes, please specify the STI(s) diagnosed and approximate date(s):
How often do you discuss sexual health with your healthcare provider?
*
At every visit
Occasionally
Rarely
Never
How comfortable do you feel discussing sexual health topics?
*
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable, 5 is Very comfortable
Sexual Orientation
*
Heterosexual
Homosexual
Bisexual
Asexual
Questioning
Prefer not to say
Other
Is there anything else you would like to share about your sexual health or history?
Submit Questionnaire
Should be Empty: