Sexual Health Questionnaire


A sexual health questionnaire can be used to find out the level of knowledge of the individuals being surveyed.  The survey of sexual health is an important exercise to carry out. The sensitive nature of such a survey needs to be taken into consideration because participants need to know that all their information will remain confidential.  This will encourage more candid responses and more willing participants.  Medical practitioners and those concerned with sexual health care can use the questionnaire to gain better insight into the sexual health of the participants.  The questionnaire should encourage the participants to be truthful and honest.

Indicate your gender: __________________________

Indicate age: _________________________________

Are you sexually active? ________________________

Do you use contraception every time you have sex?

Yes every time:

____________________________________________

Sometimes:

____________________________________________

Never:

____________________________________________

Indicate which form of contraception you use:

Condoms:

____________________________________________

The pill:

____________________________________________

The coil:

____________________________________________

The injection:

____________________________________________

Implant:

____________________________________________

Other (please specify):

____________________________________________

Where do you purchase your contraception?

Health clinic:

____________________________________________

Local chemist:

____________________________________________

School nurse:

____________________________________________

Family GP:

____________________________________________

Other (please specify):

___________________________________________

Indicate which of the following sexually transmitted diseases you are aware of:

HIV/ AIDS:

____________________________________________

Syphilis:

____________________________________________

Gonorrhea:

____________________________________________

Herpes:

____________________________________________

Chlamydia:

____________________________________________

Hepatitis B/ C:

____________________________________________

Other (please specify):

_____________________________________________

Indicate where you get most of your information on sexual health:

At Home:

_____________________________________________

In School:

_____________________________________________

Friends:

_____________________________________________

Television:

_____________________________________________

Internet:

_____________________________________________

Other (please specify):

_____________________________________________

Would you say you are well informed about your sexual health?

Yes:

______________________________________________

No:

______________________________________________

Moderate:

______________________________________________

Category: Health Questionnaire

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