1.
Within the last 12 months,
with how many partners have you had oral sex, vaginal sex and/or anal sex? _____________________
2.
Have you faced any financial barriers
to obtaining condoms or other forms of contraception?
a.
No
b.
Yes
(please explain) ______________________________________________________
3. Please
indicate which sexual activities you have engaged in.
|
Never
Engaged in activity.
|
Engaged in the activity in the past
12 months.
|
Engaged in the activity, but more
than a year ago.
|
Estimated lifetime number of partners
for that activity.
|
Giving or receiving oral sex with STI
protection (condom or other latex barrier)
|
|
|
|
|
Giving or receiving oral sex without STI
protection.
|
|
|
|
|
Vaginal intercourse with STI (ex:
condom ) and pregnancy protection (ex: birth control)
|
|
|
|
|
Vaginal intercourse with STI
protection (ex: condom )
|
|
|
|
|
Vaginal intercourse with just
pregnancy protection (ex: birth control)
|
|
|
|
|
Vaginal intercourse with NO STI or
pregnancy protection
|
|
|
|
|
Anal intercourse (received or given)
with STI protection
|
|
|
|
|
Anal intercourse (received or given)
with NO STI protection
|
|
|
|
|
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