Our doctors would now like to check your suitability for this product

Important

This questionnaire forms the basis of your online consultation. Please be honest and if you are unsure about any of your answers, please verify the information with your GP before using the service:

I am 18 years old or above.
I am using this service on my own behalf and of my own free will. Any treatment or advice is for my sole use only.
Please see your GP or go to a sexual health clinic if you have been a victim of sexual assault or violence

I confirm the above statements are true

Relationships

About you

Please confirm your gender identity

Female (including trans woman)

Male (including trans man)

Non-binary

Other

Is your gender identity the same as the sex you were assigned at birth?

Yes

Prefer not to say

Is your gender identity the same as the sex you were assigned at birth?

Yes

Prefer not to say

Is your gender identity the same as the sex you were assigned at birth?

Yes

Prefer not to say

How old are you?

Under 25

25 or older

Your sex life and relationships

Which of the following best describes your current situation?

I am in a long term relationship with one partner

I have had a new partner in the past year

I have had more than one partner in the past year

Do you have sex with men?

Yes

Prefer not to answer

Do you have sex with women?

Yes

Prefer not to answer

What type of sex do you have?
Please select all that apply.

Oral

Anal

Vaginal

Do you share sex toys?

Yes

Do you use condoms with sex toys?

Yes

How often do you use condoms for sex?

Always

Sometimes

Never

Do you use condoms for oral sex?

Yes

Have you had a condom split within the last year?

Yes

Were you or any of your partners born overseas?

Yes

Prefer not to answer

Have you or any partners used recreational drugs?

Yes

Prefer not to answer

Have you ever self injected recreational drugs?

Yes

Prefer not to answer

Have you or your partner had any tattoos, piercings or blood transfusions abroad?

Yes

Have you or any of your partners ever had sex with a sex worker or prostitute?

Yes

History

Pregnancy and breastfeeding

Are you pregnant?

Yes

Have you had an abortion or termination of pregnancy in the past month?

Yes

History of Sexually Transmitted Infections

Have you ever had any of the following?
Please select all that apply

Chlamydia

Gonorrhoea

Trichomonas

Genital Warts

Genital Herpes

HIV

Syphilis

Hepatitis B

Hepatitis C

Have you had sexual contact with a partner who has had a sexually transmitted infection?

Yes

I don't know

Do you know if your partner(s) were diagnosed with any of the following?
Please select all that apply

Chlamydia

Gonorrhoea

Trichomonas

Genital Warts

Genital Herpes

HIV

Syphilis

Hepatitis B

Hepatitis C

Other/I don't know

If you've had sex with someone who has been diagnosed with an STI, you may need treatment.

You may need treatment if a sexual partner:

has been diagnosed with chlamydia or gonorrhoea and you've had sex with them in the last 2 weeks
has been diagnosed with trichomonas and you've had sex with them in the last 4 weeks
has been diagnosed with syphilis and you've had sex with them in the last 3 months

If a partner has an STI and you've had sex with them outside this time period, or you are unsure they have an STI, you should test first.

For gonorrhoea, trichomonas and syphilis treatment, you should attend your local sexual health clinic.

If you are a contact of genital warts or genital herpes and develop symptoms, you should attend your local sexual health clinic for review or use our photo assessment service.

If you are a contact of HIV, hepatitis B or hepatitis C you should attend your local sexual health clinic for review.

If you think you have been exposed to HIV within the last 72 hours, you should seek URGENT medical advice from your local sexual health clinic, GP of Accident & Emergency. HIV Post-Exposure Prophylaxis (PEP) may be recommended to stop you developing a HIV infection.

Please confirm that you understand this

Symptoms

Most people with a STI have no symptoms and don't know they have one. Sometimes symptoms disappear but you may still have an infection and pass it on. If you have no symptoms but are concerned that you have a STI, you should get tested.

If you have certain symptoms, you may need to attend a sexual health clinic for further advice and treatment. This is important to stop you developing serious complications.

Do you have any symptoms that you think are due to a sexually transmitted infection?

No - I just want a check-up

Yes

Do you have any of the following symptoms? Please select all that apply

Unusual discharge from the vagina

Unusual vaginal bleeding e.g. heavy, between periods or during/after sex

Lower abdominal or pelvic pain

Painful sex

Pain, bleeding or discharge from the rectum

Genital ulcers or sores

Genital lumps or bumps

Fever

Symptoms

If you have certain symptoms, you may need to attend a sexual health clinic for further advice and treatment. This is important to stop you developing serious complications.

Do you have any symptoms that you think are due to a sexually transmitted infection?

No - I just want a check-up

Yes

Do you have any of the following symptoms? Please select all that apply

Painful or swollen testicles

Unusual discharge from the penis

Lower abdominal or pelvic pain

Pain, bleeding or discharge from the rectum

Genital ulcers or sores

Genital lumps or bumps

Fever

Symptoms

If you have certain symptoms, you may need to attend a sexual health clinic for further advice and treatment. This is important to stop you developing serious complications.

Do you have any symptoms that you think are due to a sexually transmitted infection?

No - I just want a check-up

Yes

Do you have any of the following symptoms? Please select all that apply

Painful or swollen testicles

Unusual discharge from the penis

Unusual discharge from the vagina

Unusual vaginal bleeding e.g. heavy, between periods or during/after sex

Lower abdominal or pelvic pain

Painful sex

Pain, bleeding or discharge from the rectum

Genital ulcers or sores

Genital lumps or bumps

Fever

Symptoms

If you have certain symptoms, you may need to attend a sexual health clinic for further advice and treatment. This is important to stop you developing serious complications.

Do you have any symptoms that you think are due to a sexually transmitted infection?

No - I just want a check-up

Yes

Do you have any of the following symptoms? Please select all that apply

Painful or swollen testicles

Unusual discharge from the penis

Unusual discharge from the vagina

Unusual vaginal bleeding e.g. heavy, between periods or during/after sex

Lower abdominal or pelvic pain

Painful sex

Pain, bleeding or discharge from the rectum

Genital ulcers or sores

Genital lumps or bumps

Fever

Symptoms

If you have certain symptoms, you may need to attend a sexual health clinic for further advice and treatment. This is important to stop you developing serious complications.

Do you have any symptoms that you think are due to a sexually transmitted infection?

No - I just want a check-up

Yes

Do you have any of the following symptoms? Please select all that apply

Painful or swollen testicles

Unusual discharge from the penis

Unusual discharge from the vagina

Unusual vaginal bleeding e.g. heavy, between periods or during/after sex

Lower abdominal or pelvic pain

Painful sex

Pain, bleeding or discharge from the rectum

Genital ulcers or sores

Genital lumps or bumps

Fever

Consent

Informed consent

I have responded honestly and provided complete and accurate information that reflects my up to date medical history and information, so that the doctor can safely assess and advise me.
I fully understand all the questions and information provided. If I am unsure about any aspect of the service I will contact Lloyds Online Doctor before proceeding.
I understand the importance of notifying my GP about medicines and advice I may receive from this service so they can continue to provide safe medical care.
I understand this consultation will form part of my Online Doctor medical record and will be kept in line with the relevant retention period.
I have read, understand and agree to the latest terms and conditions and privacy policy.
If I have further questions in relation to my sexual health or wellbeing, I will contact my GP or healthcare professional.

I confirm the above statements are true

Important

Relationships

About you

Your sex life and relationships

History

Pregnancy and breastfeeding

History of Sexually Transmitted Infections

Consent

Informed consent

% of questionnaire complete

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