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Complete ID Care Program STD ClinicINFORMATION SHEET(Please print)Name________________________________________________________________________________Date of Birth_________________________ Age________ □ Male □ FemaleBest time to call:________________________________ Phone # (______)_______________________________ *****MEDICAL HISTORY*****Current medications: ________________________________________________________________________________________________________________________________________________________Major illnesses/injuries_______________________________________________________________________________________________________________________________________________________ALLERGIES:□ None □ Penicillin □ Sulfa □ Iodine □ Latex □ Other: __________________________________________1. What is the reason for your visit? (Check all that apply) □ Have symptoms □ Think you could be at risk for an STD/HIV □ No symptoms –STD testing/screening only □ Somebody told you to come today □ Referred by another doctor or clinic □ Other:2. If you have symptoms, please check all that apply:□ Bleeding □ Pain □ Rash □ Discharge □ Sores/Blisters□ Warts □ Itch □ Problems with urination Other:____________________________________________________________________________New partner in last 90 days?□ Yes□ NoMultiple partners in last 90 days?□ Yes□ No Have you ever had an STD?□ Yes□ NoDo you use condoms?□ Yes□ NoDo you have STD symptoms? □ Yes □ No Does your partner(s) have STD symptoms? □ Yes □ No Partner(s) treated for an STD? □ Yes □ NoHow many sexual partners have you had in the last 90 days?______________________________ In your lifetime?___________________________Do you have sex with□ Men □ Women□ Both Do you have□ Vaginal Sex□ Oral Sex□ Anal Sex □ Top (Insertive) □ Bottom (Receptive) □ Both Have you ever exchanged drugs or money for sex? ? Yes ? NoHave you had sex with someone you know injects drugs?? Yes ? NoHave you ever used a needle to inject drugs? ? Yes NoHave you had sex with someone you know has HIV/AIDS? ? Yes ? NoHave you ever been in jail or prison? ? Yes ? NoDo you have any tattoos? ? Yes ? NoDo you use□ Alcohol□ Drugs□ IV Drugs Other ___________________________Are there any concerns you would like to discuss with our staff during this visit?□ No□ Yes _______________________________________________________Signature_____________________________________Date___________________________ ................
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