Questionnaire

Questionnaire

We need your help to decrease the spread of STDs and HIV/AIDS. Please, take a moment to fill out this questionnaire. It will help determine the strategies we use in the future to inform the community of things they may be doing that increase their risks. A few minutes of your time could help us save lives.

Your age:

Gender:
	Female
	Male

Race:
	White
	Black
	Asian
	LatiNo
	Other

Age when you first had sex:

Total number of people you have had sex with:

Do you have a child?
	Yes
	No

Do you use condoms?
	Never
	Always
	Sometimes

Who gets the condoms?
	Me
	My Partner
	Both of Us

What kind of sex have you had? (Mark all that apply)
	Oral Sex
	Anal Sex
	Penile/Vaginal sex
	Sex with men only
	Sex with women only
	Sex with men & women

What determines if you will have sex with a new mate?
	If I can trust them
	How long we know each other
	If it feels right
	Sometimes I get caught up in the moment
	Doesn’t really matter

How long do you need to know someone before you have sex?

Do you ask your current or new partner to get tested for STDs?
	Yes
	No

Does it matter if they have another partner/spouse?
	Yes
	No

Do you always use condoms with new partners?
	Yes
	No

How many partners do you have Now?

When do you stop using condoms in a relationship?
	I never stop using condoms
	I never use condoms
	When we really get to kNow each other
	After a few weeks
	After a few months
	After we get checked for STDs
	When we are trying to have a baby

Type of sex you usually have: (mark all that apply)
	Vaginal/Penile
	Oral
	Anal

Do you use a condom when having oral sex?
	Yes
	No

Ever Tested for HIV/AIDS?
	Yes
	No

Are you HIV positive?
	Yes
	No

Have you ever had (Mark all that apply) Syphilis?
	Yes
	No

Do you tell your partners about it?
	Yes
	No

Genital warts?
	Yes
	No

Do you tell your partners about it?
	Yes
	No

PID (pelvic inflammatory disease)?
	Yes
	No

Do you tell your partners about it?
	Yes
	No

GoNorrhea or Chlamydia?
	Yes
	No

Do you tell your partners about it?
	Yes
	No

Herpes?
	Yes
	No

Do you tell your partners about it?
	Yes
	No

Trichomoniasis?
	Yes
	No

Do you tell your partners about it?
	Yes
	No

Do you ask your partner if they or their former partners have had STDs?
	Yes
	No

If they have had STDs would it stop you from having sex with them?
	Yes
	No

How often do you get checked for sexually transmitted diseases?
	Never
	At least once a year
	When something is wrong

Where do you go to get checked?
	Private office/clinic
	Health department
	School clinic
	Community based clinic
	Emergency room

What health insurance do you have?
	None
	Medicaid
	Commercial plan (Blue Cross, etc.)

Do you use drugs or alcohol when you have sex?
	Yes
	No

Have you ever gone along with sex when you didn’t want to?
	Yes
	No

Were you afraid your mate would leave if you didn’t?
	Yes
	No

Were you afraid you would be harmed if you didn’t?
	Yes
	No

Have you ever been forced to have sex (raped)?
	Yes
	No

If yes, did you tell anyone?
	Yes
	No

Were you forced (raped) the first time you had sex?
	Yes
	No