www.ejhs.org
CONDOM USE OF FEMALE COLLEGE STUDENTS AS A FUNCTION
OF INFORMATION VERSUS ROLE PLAY AND MODELING
Lisa Kirsten Hunter
Appendix E
Sexual History Questionnaire
Instructions: Please answer the following questions by checking
a "yes" or "no" below the question. Please answer as honestly as you can.
Please be sure to answer every question.
1. In the past 3 weeks, have you had sex with anyone?
_____ Yes _____ NO
If you answered "yes," please continue to fill out the rest of the questionnaire.
2. Have you had sex with more than one partner in the past 3 weeks?
_____ Yes _____ NO
How many partners have you had sex with in the past 3 weeks?
_____ 1 partners
_____ 2 partners
_____ 3 partners
_____ 4 partners
_____ 5 partners
_____ 6 or more partners
3. In the past 3 weeks, did you have sex with someone without discussing using condoms first?
_____ Yes _____ NO
4. In the past 3 weeks, did you ever have sex when you or your partner did not use a condom?
_____ Yes _____ NO
5. In the past 3 weeks, did you have sex with someone who refused to allow condoms to be used?
_____ Yes _____ NO
6. Did you go ahead and have sex with someone in the past 3 weeks even though you thought they were not a safe partner because of their drug use?
_____ Yes _____ NO
7. Did you have sex with someone you thought does not use safer sex practices in the past 3 weeks?
_____ Yes _____ NO
8. In the past 3 weeks, have you had sex in exchange for money, drugs or a place to stay?
_____ Yes _____ NO
9. In the past 3 weeks, have you had sex with a partner you have known for less than a day?
_____ Yes _____ NO
10. Have you been pressured to have unwanted sex in the past 3 weeks?
_____ Yes _____ NO
11. In the past 3 weeks, have you had sex after using drugs or alcohol?
_____ Yes _____ NO
12. Have you had anal sex in the past 3 weeks?
_____ Yes _____ NO
13. In the past 3 weeks, have you had sex with a partner who has used IV drugs?
_____ Yes _____ NO
14. In the past 3 weeks, have you purchased any condoms?
15. In the past 3 weeks, did you ever share needles or "works" with someone else when using IV drugs?
_____ Yes _____ NO
16. Do you have condoms readily available for use?
17. Did you have sex with someone you thought might be infected with the HIV/AIDS virus in the past 3 weeks?
_____ Yes _____ NO
18. Did you have sex someone in the past 3 weeks even though you had asked them to be tested for the HIV/AIDS virus and they refused?
_____ Yes _____ NO
19. Have you ever been tested for the HIV/AIDS virus?
_____ Yes _____ NO
20. Have you ever had any sexually transmitted diseases (STDs)?
_____ Yes _____ NO
If yes, have you had any STDs in the past 3 weeks?
_____ Yes _____ NO
If yes, which STDs have you had in the past 3 weeks?
_____ gonorrhea _____ syphilis
_____ hepatitis _____ chlamydia
_____ crabs/pubic lice _____ herpes
_____ genital warts
_____ other (what?)_____________________________