Initial Health History

Sexual History Form

Please complete this form to share your health history with your provider.
Form found at: https://www.larimer.gov/health/clinical-services/clinic-forms
Please complete this form only if you have a scheduled appointment and clinical staff requested you complete this form. If you need to schedule an appointment please call 970-498-6700. Thank you.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Reason for visit:

Reproductive Health (Female/ Female assigned at birth)
Are you pregnant?

YesNo
What do you use to prevent pregnancy?
First day of your last period:
Thank you! Please click "submit" below to share this health information with your provider.
Should be Empty: