STD Health Questionnaire

It is of utmost importance that your health-care professional obtain accurate information about your current and prior sexual practices to help guide them through your STD EXAM and to help them determine which STD tests are appropriate for you. Since there are more than 20 Sexually Transmitted Diseases and hundreds of types of STD tests that can be performed it is often not practical, affordable or possible to test for all Sexually Transmitted Diseases in everyone. Furthermore, tests do not currently exist for all STD’s, such as Human Papilloma Virus in men without symptoms, so not all Sexually Transmitted Diseases can be eliminated with even the most comprehensive STD EXAM.

Below is an example of the type of questions you should be prepared to answer during an evaluation for Sexually Transmitted Diseases and your STD EXAM. It is a good idea for you to review these questions prior to your appointment. It is very important than you answer all questions honestly and to the best of your ability.

You may want to print this questionnaire, complete it and bring it with you to your health-care professional to assist them perform an accurate STD EXAM.

STD Health Questionnaire


Are you currently sexually active? No Yes

If you are not currently sexually active, have you ever been sexually active? No Yes

If you answer is yes to either of these first two questions please continue.

Do you have sex with men, women or both? Men Women Both

Are you currently in an intimate relationship? No Yes

If yes, is your current sexual partner your only sexual partner? No Yes

Have you had multiple sexual partners in your lifetime? No Yes

Within the past year, how many partners have you had? ________

Do you have vaginal sex? No Yes

Do you have oral sex? No Yes

If you have oral sex, do you give it, receive it, or both? Give Receive Both

Do you have anal sex? No Yes

If yes, do you give it, receive it, or both? Give Receive Both

For females: Is there a possibility that you are pregnant or do you desire to become

pregnant? No Yes

For Males: Are you concerned about your partner becoming pregnant? No Yes

Do you use condoms or other protection when having sex? No Yes

If you do not use condoms, why not? ______________________________

Have you ever been treated for a sexually transmitted disease? No Yes

If yes, what was the name of the STD? ____________________________________

Did you receive the treatment and complete the full course of treatment? No Yes

Has your partner ever been treated for a sexually transmitted disease? No Yes

Does your partner have symptoms now of an STD? No Yes

If you think you currently have symptoms of an STD please tell us what you think they are. _________________________________________________________

Do you think that you are at risk for HIV infection? No Yes

If you think that you are at risk for HIV please tell us why? ________________________

Have you or your partner(s) ever had a blood transfusion? No Yes

Do you or your partner(s) use alcohol? IV drugs? No Yes

Have you paid or exchanged sex for money, drugs, or shelter? No Yes