Sexual History Declaration Form
Please provide general information about your relationship and sexual health-related history. This form is for general, non-clinical purposes only.
Full Name
*
First Name
Last Name
Age
*
Relationship Status
*
Please Select
Single
In a relationship
Married
Separated
Divorced
Widowed
Other
How many romantic or sexual partners have you had in the last year?
*
Please Select
0
1
2-3
4-5
More than 5
Prefer not to say
Do you regularly discuss sexual health topics with your partner(s)?
*
Yes
No
Not applicable
When was your most recent general health checkup?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you use protection (such as condoms or dental dams) during sexual activity?
*
Always
Sometimes
Never
Prefer not to say
Have you ever received counseling or education about sexual health?
*
Yes
No
Prefer not to say
Are you comfortable discussing sexual health with healthcare professionals if needed?
*
Yes
No
Unsure
Is there anything else you would like to share about your relationship or sexual health history?
Submit Declaration
Should be Empty: