Taking A Sexual History General Health Assessment

  • How would you describe your health in the past?' - Paraphrase what they tell you. Ask for any specific chronic problems, such as diabetes, asthma, epilepsy, or skin problems that can affect their sexual health either directly or as a result of medication.
  • Have you had any surgery?' - You define for yourself if it is major or minor and whether a blood transfusion may have been given. Record how long ago, especially if before 1985 in the UK.

IF FEMALE

  • When was your last menstrual period?' - This gives you information about possible pregnancy, other hormonal problems or pituitary problems.
  • Do you have any problems with your periods - pain, heavy loss, etc? -Record the response.
  • Do you use any form of contraception?' - Describe and clarify if you haven't obtained this during the sexual history section. Describe any problems that they may disclose.
  • How many pregnancies have you had?' - This gives information on sexual activity, usage of contraception or ability to negotiate safer sex.
  • How many live births?' - Although the question is self-explanatory, it may disclose multiple miscarriages, termination of pregnancies, neonatal deaths, and previous genital infection, which in some cases can lead to miscarriage.
  • Are all your children alive and well?' This may disclose medical issues such as HIV or congenital problems. 'What ages are they now?' This may help with your HIV risk assessment if testing was offered in the antenatal check-up. (NB: This is not an essential question.)
  • When was your last cervical smear?' - If she has not had one within the last three years, give a brief reason for regular smears and explain briefly that the best way to obtain one is with her GP. If your screening is not being undertaken in the GP surgery, you may not wish to do the smear.
  • Have you been asked to re-attend sooner than the usual three years follow-up?' - Describe briefly if there is shorter recall.
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