Sexuality (Component of Social Interaction) Assessment Tool

Subjective (Reports)

Sexually active:______________ Monogamous/committed relationship:______________ 
Use of condoms:______________
Birth control method:
_________________________________________________________________________________
Sexual concerns/difficulties: Recent change in frequency/interest: Pain/discomfort:__________________________

Objective: (Exhibits)
Comfort level with subject matter:___________________________________________________________________________

Female: Subjective (Reports)
Menstruation: Age at menarche:_______ Length of cycle:_______ Duration:_______ Number of pads/tampons used/day:_______ Last menstrual
period:_______ Bleeding between periods:_______ Menopausal:_______ Last period:_______ Hysterectomy (type/date):_______ Problems
with: Hot flashes:_______ Night sweats:_______ Vaginal lubrication:_______ Vaginal discharge:_______
Gynecological/breast surgery (type and date):____________________________________________________
______________________________________
Infertility concerns:___________________________________ Type of therapy:_________________________
Pregnant now:__________________ Para:__________________ Gravida:__________________ 
Due date:__________________
Practices breast self-examination:______________ Last mammogram:______________ 
Last Pap smear/results:______________
Hormonal therapy:______________ Supplemental calcium:______________ 
Other medications/herbals:______________

Objective (Exhibits)
Breast examination:__________________________________________________________________________________
Genitalia:__________________ Warts/lesions:__________________ 
Vaginal bleeding/discharge:__________________
Test results: __________________Pap:__________________ Mammogram: STD:__________________

Male: Subjective (Reports)
Penis: Circumcised:____________________ Lesions/discharge:____________________ Vasectomy:_____________________
Prostate disorder/voiding difficulties:_______________________________________________________________________
Practice self-examination: Breast:____________________________ Testicles:____________________________
Last proctoscopic/prostate examination:____________________________ 
Last PSA:____________________________
Medications/herbals:_________________________________________________________________________________________________________________________________________________________________________

Objective (Exhibits)
Genitalia: Penis:_______ Warts/lesions:_______ Bleeding/discharge:_______ Testicles (e.g., descended, lumps):_______
Prostate:_____________________________________________________________________________________________________
Breast examination:____________________________________________________________________________
_________________________________________
Test results:_______________________________ STD:_______________________________ PSA:_______________________________