Medically Fit For Exams
Medically Fit For Exams

Basic GUM / sexual history taking

  • Wash hands and introduce yourself
  • Confirm the name and DOB of the patient
  • Ask if you can talk to the patient about their sexual history
  • Inform the patient that your conversation is confidential

 

Presenting complaint/reason for attendance

  • Symptoms
  • Duration
  • Severity
  • Change
  • Spread
  • Exacerbating/relieving factors
  • Associated factors:
    • Discharge
    • Dysuria
    • Dyspareunia
    • Pelvic pain
    • Fever
    • Lumps
    • Ulcers
  • Ask if they have had these symptoms before
  • Ask about previous STIs
    • Dates
    • Diagnosis
    • Where treated
    • Test of cure?

 

Past medical history

  • Any relevant conditions
  • Any past surgery

 

Drug history

  • Medication
  • Antibiotics
    • Affects reliability of microbial tests
  • Over the counter medication
  • Vaccinations
  • Recreational drugs/chemsex
  • Allergies
    • What happens?

 

(Females only)

Contraception

  • What method
  • Reliability (if relevant)

 

Menstrual history

  • LMP (first day)
  • Cycle length, bleeding length
  • Menstrual abnormalities
    • Menorrhagia
    • Dysmenorrhoea
    • IMB
    • PCB
  • Chance of pregnancy

 

Smear history (if >25 and <65)

  • When was their last smear and result
  • Any abnormal results in the past?

 

Pregnancies

  • Have they been pregnant before?
  • How many pregnancies?
  • How many deliveries?
  • How many children?
  • Method of delivery

 

Sexual history

  • “I’m going to ask some personal questions that we ask everyone, just to help understand what’s going on.”
  • Last sexual intercourse:
    • When was it?
    • Regular or casual partner?
    • Length of relationship
    • “Do you feel safe in this relationship?”
    • Sex of partner?
    • “Did you have vaginal sex? Oral sex? Anal sex?”
    • “Receptive or insertive?”
    • “Did you use condoms or no condoms?”
    • Consistency of condom use
    • Nationality of partner
  • Repeat for previous sexual partners for the past 3 months
    • Combine if there are many

 

Last passed urine

  • How long since they passed urine?
    • Needs to be several hours since passed urine for some tests to be accurate

 

HIV risk assessment

  • Have you had an HIV test before?
    • When was most recent?
    • Result?
  • Have you had a partner known to be HIV positive?
  • IV drug use or sex with an IV drug user
  • Have you had sex with a man (men) or have any of your partners had sex with a man (women)
  • Sexual partners outside Europe
  • Have you ever paid for or been paid for sex?
  • Medical treatment or blood transfusions abroad?
  • Tattoos or piercings abroad?

 

Social history

  • Smoking
  • Drinking
  • Drug use
Basic GUM history.docx
Microsoft Word document [15.3 KB]

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