Female Sexual Health Evaluation Form

Full Name

Age

Marital Status

Occupation

Relevant Medical History

Current Medications

Allergies

Menstrual History

Obstetric History

Do you experience any of the following?

Pain during intercourse Vaginal dryness Low sexual desire Difficulty with arousal Difficulty achieving orgasm Other

When did these symptoms begin?

How often do the symptoms occur?

Severity of symptoms

Are you sexually active?

Yes No

If yes, is it with:

Current relationship satisfaction

Any history of sexual trauma or abuse?

Yes No Prefer not to answer

Additional information or concerns