Survey Form for Impact of COVID-19 on Reproductive & Sexual Health Adolescents & Young Adults

With the COVID-19 Pandemic and the lockdown since March 2020, has it affected you in any of the following parameters?

Sexual Behavior Questions

1. Are you

2. How old are you?

3. If single, with whom do you live with?

4. Have you ever been sexually active?

5. Have you been sexually active during the lockdown?

6. Has anyone close to you tried to misbehave with you during the lockdown?

Contraception Behaviors

7. Did you use any form of contraceptive method the last time you were sexually active?

8. What type of contraceptive method did you use and how often do you use it?


Oral contraceptive Pills

Withdrawal Method

Emergency Pill (I Pill)

Safe period/calendar method

9. Difficulty to assess any sexual and reproductive health services when needed?

Contraceptive counseling

Contraceptives, including emergency contraceptives

Oral contraceptive pill


Emergency contraceptive (EC) pill

Safe abortion care

If yes, medication to induce abortion

If yes, access to surgical abortion

Menstrual health Questions

Male participants to skip this section.

10. Managing your menstruation: availability of products during lockdown?

Sanitary napkins


Panty Liners

Menstrual cup

11. How did you manage your periods?

Mental Health & Psychological Support

12. Have you ever been diagnosed by a doctor or therapist with one or more of the following before the lockdown?

If Yes, mark which one.

13. Have you ever received counseling?

14. How were you receiving counseling (face-to -ace, digitally, etc)

15. Under the lockdown, do you feel :






16. How anxious are you about COVID-19? On a Scale of 1to 5, 1: being not anxious to5: being extremely anxious. Select the appropriate number

17. If you received counseling digitally, how satisfied were you with your treatment? On a Scale (1 to 5) from not satisfied at all to extremely satisfied.

Social Isolation

18. Since learning about COVID-19, have you had less communication with family and friends?

19. Since learning about COVID-19, have you been more worried about going to public places, such as school, health centers, market, or community centers?

20. Due to COVID-19, has anyone in your household stopped you from

Leaving the house

Going to work

Going to school

21. How has your participation in domestic work changed during the lockdown?

22. I feel that there is always someone I can talk to about my day-to-day problems.

23. Under the lockdown, how often do you meet personally or online with your friends?