SCREENING QUESTIONNAIRE FOR LOCALIZED AND/OR SYSTEMIC
SEMINAL PLASMA HYPERSENSITIVITY SYNDROME

Localized seminal plasma hypersensitivity is characterized by localized vaginal pain and burning that occurs immediately after contact with seminal fluid. The pain is very severe and can last hours to days.

Systemic seminal plasma hypersensitivity is a condition where an individual experiences some or all of the following symptoms immediately (up to 60 minutes) after direct contact with seminal fluid: hives, soft tissue swelling (angioedema), chest tightness, shortness of breath, wheezing, diarrhea, dizziness and/or loss of consciousness.

Answer the following questions as they relate to your condition; refer to the above definitions while answering these questions.
   
1. Do you experience a burning sensation during or after ejaculation?
  yes   no
   
1b. Do you experience symptoms consistent with systemic allergy reaction during or after ejaculation?
  yes   no
   
2. Do you experience a burning sensation if you come in contact with semen on your skin or orally?
  yes   no
   
2b.

Do you experience a systemic allergic reaction if you come in contact with semen on your skin or orally?
  yes   no
   
3. Does your sexual partner experience a burning sensation of his skin when he comes in contact with his semen?
  yes   no
   
3b. Does your sexual partner experience symptoms of a systemic reaction after he comes in contact with his own seminal fluid on his skin?
  yes   no
   
4. Does this burning sensation go away when you use a condom during sexual intercourse?
  yes   no
   
4b.

Do symptoms of a systemic allergic reaction go away when you use a condom during sexual intercourse?
  yes   no
   
5. Have you sought medical attention for this problem?
  yes   no
   
6. Have you been treated for any sexually transmitted diseases such as gonorrhea, syphilis cytomegalovirus herpes virus, papilloma virus, hepatitis or human immunodeficiency virus?   
  yes   no
   
7. If yes to question 6, please list which conditions you have been diagnosed and treated for.
 
 
 
   
 
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