Frankford Hospitals - Center for Gynecology & Women’s Health at Frankford Hospitals

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Center for Gynecology & Women’s Health at Frankford Hospitals

Sexually Related Infections Risk Assessment

Women can answer the following questions to get a sense of their
likelihood of having or developing a sexually transmitted disease (STD).

Are you experiencing vaginal itching?	Yes	No
Are you experiencing vaginal discharge?	Yes	No
Are you experiencing vaginal odor?	Yes	No
Do you douche?	Yes	No
Do you notice scabs, rashes, bumps, or other skin changes on your genitals?	Yes	No
Are you experiencing a burning sensation in your genitals or urinary tract?	Yes	No
Are you experiencing pain in your pelvis, genitals, or urinary tract?	Yes	No
Are you experiencing general symptoms of infection such as fever or chills; aches and pains; or swollen glands?	Yes	No
Do you have irregular vaginal bleeding?	Yes	No
Do you have bleeding after intercourse?	Yes	No
Are you under 25 years of age?	Yes	No
Have you had a recent (in last six months) change in sexual partner?	Yes	No
Do you have more than one sexual partner?	Yes	No
Have you had more than three sexual partners during the last six months?	Yes	No
Does your sexual partner have other sexual partners?	Yes	No
Have you had unprotected sex or made inconsistent use inconsistently (not every time)?	Yes	No
Do you have unexplained weight loss or night sweats?	Yes	No
Do you experience otherwise-unexplained gastrointestinal symptoms, or signs of jaundice (yellow skin and whites of eyes, darker-yellow urine, and pale feces)?	Yes	No
After oral sex, have you developed a sore throat that has persisted?	Yes	No

The more often you answered “Yes” to the above questions, the greater your risk for contracting or already having a sexually transmitted disease. If you answered “Yes” to questions above, consider discussing sexually related infections with one of our Women’s Center healthcare providers.

Print this page and bring it with you, filled out, to your appointment.

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