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The Sexual Problems Questionnaire

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The Sexual Problems Questionnaire The Northern Contraception, Sexual Health & HIV Service The Hathersage Centre 280 Upper Brook Street Manchester M13 0FH Tel: 0161 701 1555 THE SEXUAL PROBLEMS QUESTIONNAIRE We keep all this information private and confidential It will help us if you can answer the following questions. Please use the back of this form or another sheet of paper if there is not enough space for your answers. Name…………………………………………Age………….DOB………………………M/F Address………………………………………………………………………………………… Contact telephone number…………………………………………………………………… GP Name/Address……………………………………………………………………………. Please tick box Are you: Married Single Separated Living with partner Divorced Remarried Widow Widower If you have any children, please write down their names, ages and sex. Please tick box Are you in work Yes Full time No Part time What sort of job do you do? www.mft.nhs.uk Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services PAST HISTORY How would you describe the quality of your relationship within your family while growing up? Relationship with mother: Relationship with father: Relationship with brothers / sisters Do you remember any particular happy or unhappy times or events in your childhood / adolescence? Please say something about your past sexual experiences and relationships. www.mft.nhs.uk Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services GENERAL INFORMATION 1. Are you currently on any prescribed medication? YES/NO If yes please give details 2. How much alcohol do you drink in an average week? Beer/lager/cider ………………………Pints Wine ……………………….Glasses Spirits ……………………….Single measures 3. Do you take any non-prescribed drugs YES/NO If yes please give details 4. Do you smoke? YES/NO If yes how many cigarettes do you smoke per day? ……….. If you are an ex-smoker how many cigarettes a day did you smoke? 5. What kinds of contraception do you use? 6. Do you suffer from any permanent disability? If yes please give details. 7. Have you ever had any previous psychological/psychiatric treatment? If so please give details. 8. Please tell us about any serious health problems. www.mft.nhs.uk Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services HEALTH MEDICAL INFORMATION MEN 1. Do you have any problems with getting an erection? YES/NO 2. Do you get erections during the night or when you wake up in the Morning? YES/NO 3. Are you able to masturbate? YES/NO And ejaculate? YES/NO 4. Have you ever had any kidneys or prostrate problems? YES/NO If yes, please give details. 5. Have you ever had any abdominal/pelvic surgery? YES/NO If yes, please give details. www.mft.nhs.uk Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services HEALTH MEDICAL INFORMATION WOMEN 1. Have you ever had any vaginal or bladder problems? If yes, please give details. 2. Have you ever had any other gynaecological (‘womens’) problems? If yes, please give details. 3. Please give details about any pregnancies you have had 4. Do you have any problems with your periods? If yes, please give details. 5. Do you use tampons? YES/NO Have you ever used tampons in the past? YES/NO 6. Do you have any problems with the menopause (change of Life)? If yes, please give details. 7. Are you currently on HRT? If yes, please give details. 8. Have you ever had any pelvic gynaecological surgery? If yes, please give details. www.mft.nhs.uk Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services CURRENT AIMS 1. Write down in your own words why you want to come to the clinic and how you think we might be able to help. Tell us how long you have had these problems. 2. Have you ever had specific sexual or couple therapy? Yes/No If yes, please give details (who, where) and outcome. 3. Please add any further information you feel would help us understand your situation www.mft.nhs.uk Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services .
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