• STD

  • Date of Birth*
     - -

  • Sexual activity is defined as oral, vaginal, or anal sex with another individual.   

  • Have you been sexually active in the last 6 months?*
  • How many people have you had sexual activity with in the last 6 months?*
  • Have you had sexual activity without a condom in the past 6 months?*
  • Have you had sex in exchange for money or drugs in the past 6 months?*
  • Have you ever had or been treated for syphilis, gonorrhea or chlamydia in the past 6 months?*
  • Have you ever been tested for HIV?*

  • This patient has been engaging in high risk sexual activity and should be screened for sexually transmitted diseases.

  • The patient should receive HIV screening.

  • Today's Date
     - -
  • Should be Empty: