Sexual Health Assessment

Information will be kept confidential. If you have any questions or concerns please contact the HERC at (217)581-7786 or the Health Service Medical Clinic at (217)581-2727. You may also call the sexual health coordinator, Madison, to schedule a one-on-one meeting to discuss the risks of sexual behavior.

Please be aware that assessments received through this portal will be kept confidential. However, please understand that this is NOT a secure portal. In other words, information may be intercepted by unauthorized individuals. Please be aware of this risk.
Additionally, by submitting this form, you are aware that feedback provided is for informational purposes only and should not replace the advice and consultation of a licensed health care professional. * I have read and understand the preceding information.
If you prefer not to submit this form electronically, you may complete, print, and mail to the Health Education Resource Center.
What prompted you to come in for STI/STD and/or HIV testing at this time
(Please check all that apply) * Starting or ending a relationship Possible exposure Have symptom or partner has symptom Want to know my status Sexual Assault
With whom are you sexually active? *
Number of lifetime sexual partners (includes engagement in all sexual activities: oral, anal, and/or vaginal). *
When was your last STI/STD testing? * Less than 1 year More than 1 year Never
When was your last HIV testing? * Less than 1 year More than 1 year Never
Have you been immunized against Hepatitis B? * Yes No Don't Know
If engaging in heterosexual intercourse, do you use contraception? *
If you answered yes to #6, please list the method/methods.
Have you ever had a sexually transmitted infection? *
If you answer yes to #8, please identify the infection/infections.
Have you ever had any undiagnosd genital sores or had a partner with known Herpes? *
Have you ever had genital to genital contact without protection? *
Have you ever had oral to genital contact without protection? *
Have you ever had genital to anal contact without protection? *
How often do you use condoms? * Rarely Often Always n/a
Have you been told or suspect you have been in contact with a STI/STD? * Yes No Don't Know
Have you shared needles or had a partner who has shared needles? * Yes No Don't Know
Have you or a partner had sex for drugs or money? * Yes No Don't Know
Have you had sex when drugs or alcohol impaired your judgment *
Do you have tattoos or body piercings? *
Do you have any concerns or questions?
Your e-mail address *

Required for risk assessment feedback. If you prefer, you may also print this form and mail or deliver to the Health Education Resource Center located in the Student Services Building.