Sexually Transmitted Disease Survey Template

Healthcare survey template on Sexually Transmitted Infections.



   
 
 


Please take a few minutes to fill out this survey on sexually transmitted diseases. Your responses will be kept confidential. Thank you for your input.

 
   
 
1. What is your gender?
 
Male
 
Female
 
   
 
2. Have you ever been tested for an STD before?
 
Yes
 
No
 
   
 
3. Are you sexually active?
 
Yes
 
No
 
   
 
4. If yes, have you recently had sexual intercourse?
 
Yes
 
No
 
   
 
5. Have you ever had an STD?
 
Yes
 
No
 
   
 
6. If you answered No, how do you know?
 
I have never had sexual intercourse
 
I have been tested
 
I have never had any symptoms
 
Other
 
   
 
7. Which of the following forms of protection against STD do you prefer?
 
Condoms
 
Vaccination
 
None
 
N/A
 
   
 
8. Are you aware that you can contract STD through any of the following means?
 
Vaginal penetration
 
Yes
 
No
 
Not sure
 
   
 
9. Anal sex
 
Yes
 
No
 
Not sure
 
   
 
10. Oral sex
 
Yes
 
No
 
Not sure
 

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