Mastermind Recovery STI Clinic Questionnaire
Personal Information
Full Name
First Name
Middle Name
Last Name
Age
Sex
Please Select
Male
Female
Trans Male
Trans Female
Non-binary
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
PARTNERS
Are you currently have sex of any kind?
Yes
No
If yes, which type? (Select all that apply)
Oral
Vaginal
Anal
I'm not having sex
If no, have you ever had sex of any kind with another person?
Yes
No
In recent months, how many sex partners have you had?
What is/are the gender(s) of your sex partner(s)?
Do you or your partner(s) currently have other sex partners?
Yes
No
Not Sure
Practices
What kind of sexual contact do you have, or have you had?
What parts of your body are involved when you have sex?
Do you meet your partners online or through apps?
Yes
No
Have you or your partners used drugs?
Yes
No
Have you ever exchanged sex for your needs (money, housing, drugs, etc.)?
Yes
No
Protection
Do you and your partner(s) discuss STI prevention?
Yes
No
If you use prevention tools, what methods do you use? (For example, external or internal condoms - also known and male or female condoms - dental dams, etc.)
How often do you use these methods?
Have you received HPV, hepatitis A, and/or hepatitis B shots? (check all that apply)
No, None of them
HPV shot
Hepatitis A shot
Hepatitis B shot
Are you aware of PrEP, a medicine that can prevent HIV?
Yes
No
If so, have you ever used it or considered using it?
Yes
No
Past
Have you ever been tested for STIs and HIV?
Yes
No
Would you like to be tested?
Yes
No
Have you been diagnosed with an STI in the past?
Yes
No
If so, when? And did you get treatment?
Have you had any symptoms that keep coming back?
Yes
No
Has your current partner or any former partners ever been diagnosed or treated for an STI?
Yes
No
If yes, were you treated for the same STI(s)?
Do you know your partner(s) HIV status?
Pregnancy
Do you think you would like to have more children at some point?
Yes
No
Not sure
If so, when do you think that might be?
How important is it to you to prevent pregnancy (until then)?
Very Important
Somewhat Important
Not important
I want a child asap
Are you and your partner using contraception or practicing any form of birth control?
Yes
No
Would you like to talk about ways to prevent pregnancy?
Yes
No
Do you need any information on birth control?
Yes
No
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: