Request edit access
JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Nakshatra plus - sexual high risk behaviour assessment questionnaire for STD/HIV/AIDS
Sign in to Google
to save your progress.
Learn more
Your Sparkling Skin & Sexual Health Clinic
This questionnaire is intended for persons who wish to assess their risk of acquiring STD/ HIV infection through sex. Confidentiality will be maintained for all your queries/ information.
Your answer
What is your age
less than 18 years
19-34 years
35-55 years
more than 55 years
do not wish to answer
Clear selection
Sex
Male
Female
Transgender
Prefer not to say
Other:
Clear selection
Are you married?
Yes
No
Do not wish to answer
Clear selection
If married , what is your current status?
Living with spouse
Living with a non marital partner
Separated
Divorced
Spouse expired
Do not wish to respond
Not applicable
Clear selection
Have you had sex with anyone outside marital relationship?
Yes
No . If no , kindly skip to the last question
Clear selection
With whom all have you had sex?
Male
Female
Transgender
Other
Was this the first time you had sex?
Yes
No
Clear selection
When was the recent sexual encounter ?
Less than a week
More than a week to less than a month
More than a month to less than a year
More than a year
Other:
Clear selection
How did you know/meet your sex partner ?
Neighbour
School friend
College friend
Colleague at work place
Family friend
Internet dating site
Facebook / whats app friend
Sex worker
Escort
Other:
Clear selection
Why did you have sex ?
Had an opportunity , so had sex
Wanted to experiment/ have sex for fun / enjoyment
My friends had similar experience. So I wanted to have
I was drunk/ having drugs
Do not wish to answer
Other:
What type of sex did you have ? (multiple answers possible)
Vaginal
Oral
Anal
Thigh sex
Kiss
Breast fondling
Mastrubation
Mutual mastrubation
Sex toys
Other:
If you had penetrative sex, did you or your sex partner use any protective method ?
Yes
No
Did not have penetrative sex
I dont remember
Clear selection
If yes ,what protective method did you or your partner use ?
Male condom
Female condom
Other:
Did you have any symptoms in your genitals/ anal region/ mouth/ skin after the sexual exposure?
If Yes - please skip to the next question
If No - please go to the last question
Other:
Clear selection
Please describe your symptom
Your answer
Did you consult a doctor ?
Yes
No
Other:
Clear selection
Did you test yourself for any STD/ HIV?
Yes
No
Other:
Clear selection
Did you take complete treatment ?
Yes
No
Clear selection
Do you feel you are at risk for acquiring any sexually transmitted diseases/ HIV?
Yes
No
Maybe
Clear selection
How did you know about Nakshatra Sexual health online support service?
Whats app
Internet / You tube / website
Friends / family members
Phone call services
Other:
Clear selection
For information ,please feel free to contact Nakshatra Plus clinic , Kolathur, Chennai - +91 9500059746 or whats app or
nakshatrahealth@gmail.com
.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
