Sexual History Case A Lucy Lock

Simulated Patient: Jessie Lock

  • Age: 20
  • Assigned sex at birth: Female
  • Gender: Non-binary (they/them)
  • Presenting complaint: “I want to have some tests done to see if I am healthy.”

Assessment Domains & Criteria

Domain Criteria Marks Comments
1. Introduction & Rapport Greets the patient respectfully and introduces self with name and role

1

 
  Confirms patient name and preferred pronouns, uses them correctly throughout

2

 
  Establishes a safe and non-judgmental environment (verbal and non-verbal cues)

2

 
Subtotal  

/5

 

Domain Criteria Marks Comments
2. Presenting Complaint Elicits the patient’s reason for the visit using open-ended questions

1

 
  Clarifies what the patient means by “tests to see if I’m healthy”

1

 
  Explores symptoms (rash, concerns about STIs) appropriately and sensitively

2

 
Subtotal  

/4

 

Domain Criteria Marks Comments
3. Focused History Taking Asks about recent sexual activity with attention to consent and comfort

1

 
  Explores sexual practices and partners in a respectful and inclusive way

2

 
  Asks relevant menstrual, contraception, or STI history (as appropriate)

1

 
  Screens for symptoms (e.g., pain, discharge, systemic signs)

1

 
  Asks about past testing or vaccination (e.g., HPV, Hep B)

1

 
Subtotal  

/6

 

Domain Criteria Marks Comments
4. Communication Skills Uses inclusive, non-judgmental, and gender-affirming language

2

 
  Demonstrates active listening, empathy, and validation of concerns

2

 
  Avoids assumptions about sexual orientation, gender, or behavior

1

 
Subtotal  

/5

 

Domain Criteria Marks Comments
5. Summarising & Closure Summarises main concerns accurately and checks patient’s understanding

1

 
  Provides brief explanation of next steps (e.g., STI testing, confidentiality)

1

 
  Thanks the patient and offers reassurance or follow-up

1

 
Subtotal  

/3

 

Domain Criteria Marks Comments
6. Ethical Awareness Demonstrates understanding of confidentiality and consent

1

 
  Responds appropriately to sensitive disclosures

1

 
Subtotal  

/2

 

Total Score:    /25


Global Rating Scale (Tick One):

Excellent – Clear, confident, respectful; meets all criteria; patient would feel safe

Good – Mostly complete, minor gaps; good rapport

Borderline – Incomplete history or awkward communication; needs support

Unsatisfactory – Misses key information; uses inappropriate or insensitive language

Dangerous – Breaches confidentiality; dismissive or harmful communication