HEALTH SERVICES

STD Questionnaire

 

 

 

Name:____________________________________Phone:_________________

 

Date:________________________________Date of Birth:_________________

 

All information is private and remains confidential

 

1.  At what age did you become sexually active?__________________________

 

2.  How many partners have you had?         Lifetime partners__________________

 

                                                                        Partners this year__________________

 

3.  Have you had unprotected vaginal/anal/oral sex (sex without using a           condom)?       □Yes         □ No

 

4.  Have you had any experience with intravenous drug use?      □Yes        □No

 

5.  Have you had problems with unusual infections, unexplained fatigue, night sweats, chronic diarrhea or unexplained weight loss?        □Yes         □No

 

6.  For females only:  Have you had any abnormal vaginal discharge, pain during intercourse or bleeding between menstrual periods?         □Yes         □No

 

7.  For males only:  Have you had a discharge from the penis, a burning sensation when urinating or burning or itching around the opening of the penis?

□Yes         □No

 

8.  Have there been any unusual blisters, bumps,  or sores in your genital area?

□Yes         □No

 

9.  Have you or a partner had a positive STD test in the past?     □Yes         □No

 

10.  For females only:  Have you had the HPV vaccine?              □Yes         □No

 

 

To protect yourself, remember these ABC’s

A=Abstinence

B=Be faithful

C=Condoms