STI Clinic Intake

1
Who is filling out this form?* This field is required.
I am the patient, the patient's parent/guardian or the patient's legal representative
Springfield-Greene County Health Department staff member
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SGCHD pin* This field is required.
3
Sorry, this option is only available for Springfield-Greene County Health staff members.
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Patient's full name* This field is required.
First Name
Last Name
5
Patient's date of birth* This field is required.mm-dd-yyyy
Date
Month
Day
Year
6
Email* This field is required.Please provide the patient's email, or the email of the patient's parent/guardian or legal representative
example@example.com
7
Primary phone number* This field is required.Please provide the patient's phone number, or the phone number of the patient's parent/guardian or legal representative
Please enter a valid phone number.
8
Last 4 digits of patient's Social Security Number* This field is required.
9
Patient's address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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What county does the patient currently reside in?* This field is required.
11
Patient's race* This field is required.Please select all that apply
American Indian/Alaska Native
Asian
Black/African American
Pacific Islander
White
Decline to respond
Other
12
Patient's ethnicity* This field is required.
Hispanic/Latinx
Not Hispanic/Latinx
MENA (Middle Eastern North African)
Decline to respond
13
What is the patient's preferred language?* This field is required.
14
Patient's sex assigned at birth* This field is required.
Male
Female
Decline to respond
15
Patient's current gender identity* This field is required.
Man
Woman
Transgender man
Transgender woman
Genderqueer
Decline to respond
16
Patient's gender pronouns* This field is required.
She/her
He/him
They/them
Decline to respond
Other
17
Patient's sexual orientation* This field is required.
Bisexual
Straight/Heterosexual
Lesbian, Gay or Homosexual
Unsure
Decline to respond
Other
18
Patient's insurance status* This field is required.
Private or Employer insurance
Medicare
Medicaid
Underinsured
Uninsured
Decline to respond
19
Is the patient now, or have they ever considered themselves, unsheltered or homeless?* This field is required.
YESNO
20
Is the patient now, or have they ever considered themselves, unsheltered or homeless?* This field is required.
Yes
No
21
Has the patient ever received clinical services at the Health Department?* This field is required.
Yes
No
Unsure
22
Has the patient been seen at the Health Department STI Clinic in the last 3 months?* This field is required.
YESNO
23
What services did the patient receive during their most recent visit?* This field is required.
Urine test for chlamydia and gonorrhea
Blood test for HIV, syphilis, hepatitis B or hepatitis C
Both
24
In the last 2 months, has the patient or a sexual partner of the patient tested positive for chlamydia, gonorrhea or syphilis?* This field is required.
Yes, I have
Yes, my partner has
No
25
Can the patient verify their partner's positive results?* This field is required.To verify a partner's results for chlamydia, gonorrhea or syphilis, the patient will be asked to verbally provide their partner's name, date of birth, where they tested and what they tested positive for. If their partner tested outside of Missouri, the patient must provide a physical copy of their positive results with their name, date of birth and where they were tested.
YESNO
26
The patient is not eligible for testing at this time.

However, the patient may be able to be seen by a nurse to begin treatment. Please call 417-864-1408 to speak with a nurse.

Please close out of this page and do not click submit. Thanks!
27
The patient is not eligible for testing at this time.

Since partner test results cannot be verified and the patient has received all available testing at our clinic in the last 3 months, they are not able to be tested at this time. Please check back after the 3-month period has passed or when partner test results have been verified.

Please close out of this page and do not click submit. Thanks!
28
The patient is not eligible for testing at this time.

Since the patient has received all available testing at our clinic in the last 3 months, they are not able to be tested at this time. Please check back after the 3-month period has passed.

Please close out of this page and do not click submit. Thanks!
29
Which of the following symptoms does the patient have?* This field is required.Please select all that apply.
Abnormal bleeding
Burning during urination
Cramping
Discharge
New rash on palms, soles of feet or torso that is currently present
New sore/lesion on genitals that is currently present
No symptoms
Other
30
Does the patient have sex with males?* This field is required.
YESNO
31
Does the patient have sex with females?* This field is required.
YESNO
32
What type of sex does the patient engage in?* This field is required.Please select all that apply
Vaginal
Anal/Rectal
Oral
Decline to respond
33
Is the patient or the patient's partner pregnant?* This field is required.
YESNO
34
Please select test type* This field is required.Select all that apply
Urine test for chlamydia and gonorrhea
Blood test for syphilis and/or HIV
Blood test for hepatitis B and hepatitis C
35
Notice

We are unable to run tests for hepatitis B and hepatitic C after 12 p.m. on Thursdays. Please do not schedule a hepatitis B or C blood test on Thursday afternoons. We will not be able to complete the test and the appointment will be canceled.
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Please select a testing time* This field is required.Appointments are available on Tuesdays, Thursdays and Fridays, 8:40-11:20 a.m. and 1-3 p.m. You may schedule up to 7 days in advance.
37
Emergency contactThis is optional
Emergency contact name
Emergency contact phone number
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Notice of Privacy Practices
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Please explain why you refuse to acknowledge receipt or offer of this office's Notice of Privacy Practices.* This field is required.
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Policy and Service Agreement* This field is required.
41
Signature of patient or legal representative* This field is required.
Should be Empty:

The patient is not eligible for testing at this time.

The patient is not eligible for testing at this time.

The patient is not eligible for testing at this time.

Notice