| Brief Personal History - For Women |
| Name:__________________________________ Phone Number___________________ |
| Address:________________________________ |
| DOB__________________ Place of Birth___________________ Highest level of Education__________ |
| Where did you grow up____________________________________________________ |
| Height______________ Weight_____________ Brothers and Sisters____________________________ |
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Medical Problems:
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Prescription Medications (Name, Dose, number of times taken per day)
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Over the Counter, Herbal, Special health foods Vitamins, Supplements
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Description of your problem/concern:
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| History: (circle and explain) |
| Breasts: Normal/Abnormal Explain:________________________________________________________ |
| Cosmetic Breast Surgery: Augmentation/Reduction |
| External Genitalia (Vulva): To include Vaginal
Opening, Urethra, Clitoris: Normal/Abnormal Explain:______________________________________________________ |
| Pubic and Underarm Hair: Normal/Abnormal Explain:_________________________________________ |
| Facial Hair : Normal/Abnormal Explain:_____________________________________________________ |
| Menstruation (Periods) : Normal/Abnormal Explain:___________________________________________ |
| Hysterectomy: Yes/No When___________ |
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Orgasm: Normal/Abnorma Explain:_________________________________________________________ |
| Age of first Orgasm___________By: Masturbation/ Intercourse/ Other |
| Do you masturbate: Yes/No How often:_____________________________________________ |
| Age of first sexual encounter with another person: ____________ Male/Female |
| Same sex experiences as adolescent or young adult: Yes/No |
| History of Sexual Abuse: Yes/No (explain on separate sheet) |
| Have you ever paid for sex: Yes/No |
| Have you ever been paid to have sex with someone: Yes/No |
| Have you ever been arrested, dealt with the police
or the law concerning any sexual matters: Yes/No Explain______________________________________________________________________________ |
| Do you use erotic literature, erotic videos,
or sex toys to enhance sexual activity: Yes/No Explain______________________________________________________________________________ |
| Do you have any religious or moral concerns about
any sexual activities: Yes/No Explain_________________________________________________________________________ |
| Sexual Orientation - How do you see yourself
on the scale: Heterosexual 1 2 3 4 5 6 7 Homosexual |
| Sexual partner: Yes/No-- Male/Female-- Living
Together: Yes/No-- Time Together__________________ Married: Yes/No |
| How often (on average) do you have intercourse: _____________________________________________ |
| Previously married: Yes/No |
| Number of children: ___________ Ages: Male: ______________ Female _________________________ |
| Do children live with you? Yes/No |
| Do you have a blended family with your partner (her children/your children) Yes/No |
| Do you smoke to: Yes/No - Do You use Alcohol
Yes/No - Do you Use drugs Yes/No What Kind: ______________________ How Often: ________________________ |
| Are you employed: Yes/No - Type of Work: _______________________________ |
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Memories of sexual problems/concerns with initial sexual experiences:
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