Sexual Health Survey

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DO NOT write your name on this survey. The answers you give will be kept private. No one will know what you write. Answer the questions based on what you really think and really do.

Make sure to read every question. Some questions may not apply to you, and you should skip over them.

What is the purpose of the questionnaire?
You are being asked to take part in a general survey to explore people’s sexual health needs. This information will be used by Ancestral Herbiary's team to inform the development and delivery of local services. Even if you have never used a sexual health service we still want to hear your views.

Will my taking part in the study be kept confidential?
Yes. We take confidentiality very seriously. The survey does not ask for names or addresses so no-one will know you have taken part and your answers cannot be traced back to you. All surveys will be kept on a secure, password protected computer. Any paper surveys will be kept in a locked cabinet. Please be aware that, because we do not take names, it is unlikely you would be able to withdraw your answers from the study after you have returned the survey.

What do we mean by sexual health?
Sexual health services offer information, safe-sex advice and treatment to do with contraception and sexually transmitted infections (sometimes called STDs), HIV, & Pregnancy.

What’s involved?
The survey asks for brief information about you, your knowledge, awareness and opinions of sexual health services. We will also ask you a small number of questions about lifestyle, to get a picture of your general health. This survey should take 10-15 minutes to complete depending on how much information you want to provide.

Are there any risks/benefits to being involved?
There are no direct risks or benefits to you being involved in the study, but the information you provide will be used to help develop services for you and others.

Contact details
If you have any questions or would like to discuss the study, please contact:
Iya Ifayomi Fasola
info@ancestralherbiary.com

Thank you very much for your help.

How old are you/

Under 16

16-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60+

Prefer not to say

Clear selection

Which of the following best describes you?

Black or African American

White or Caucasian

Asian or Pacific Islander

Hispanic or Latino

Native American

Multiracial or Biracial

Prefer not to say

Clear selection

How would you describe your sexuality?

Heterosexual (straight)

Homosexual (gay or lesbian)

Bisexual (attracted to both men & women)

Transsexual (a gender identity or gender expression that differs from the sex that they were assigned at birth)

Asexual (does not experience sexual attraction toward individuals of any gender)

Unsure

Prefer not to say

Clear selection

What is your gender?

Male

Female

Clear selection

Gender: Please describe how you identify:

Woman

Man

Non-Binary

Prefer not to disclose

Clear selection

How would you describe your general health?

Very Good

Good

Okay

Poor

Very Poor

Prefer not to say

Clear selection

Are you currently disabled? (i.e. hard of hearing, dyslexia, etc)

Yes

Prefer not to say

Clear selection

Do you have a long-term physical or mental health condition? (i.e. diabetes, depression, anxiety, etc)

Yes

Prefer not to say

Clear selection

Clear form

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