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, Quelques questions pour mieux vous connaître 1. Age : |_|_| ans 2. Avec qui vivez-vous ? (plusieurs réponses possibles) ? Père ? Beau-Père ? Autre (précisez)?????

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, Si oui de quand date votre dernière visite chez le gynécologue ?, Mois : | _|_| Année : |_|_|_|_| ? ne sait pas

, Avez-vous déjà eu des rapports sexuels ? ? Oui ? Non ? Ne souhaite pas répondre

, Si oui quel âge aviez-vous lors de votre premier rapport sexuel ? |_|_| ans ? Ne souhaite pas répondre

, Avez-vous un moyen de contraception ?