Microsoft word - sti vaginitis medical visit 10-2012
This medical record is confidential and will not be released to anyone except as may be required by law.
St. Croix County DHHS-Public Health Dept.
1445 N 4th Street, New Richmond, WI 54017
Name _____________________________________________________ Date of Birth ___________________ Age _____________ Last First M Reason for visit: ____________________________________________ Phone # to contact you: _______________________________ Please check if you are allergic to: No Allergies Penicillin
Other _________________________________
List medications, vitamins, over the counter drugs, and/or herbs you take:_____________________________________________________
MENSTRUAL HISTORY Day last period began:____________________ Was it normal? yes no Have you had sex since your period? yes no CONTRACEPTIVE HISTORY Are you using a method of birth control now? yes no If yes, what kind? _____________________________ Do you use condoms? yes no sometimes SEXUAL HISTORY Have you had more than one sexual partner in your lifetime? yes no Check if you have: vaginal sex oral sex anal sex sex with men sex with women sex with both Check if your partner(s) have: vaginal sex oral sex anal sex sex with men sex with women sex with both Have you had a new partner or more than one partner in the last 90 days? yes no don’t know Has your partner(s) had a new sex partner or more than one partner in the last 90 days? yes no don’t know Have you had symptoms or a diagnosis of an STI in the last 90 days? yes no don’t know Has your partner(s) had symptoms or a diagnosis of an STI in the last 90 days? yes no don’t know Have you or your partner(s) used IV drugs? yes no don’t know Have you ever had? Chlamydia Gonorrhea HPV/warts Herpes Syphilis Have you had Chlamydia in the last 5 years? yes no REVIEW OF SYSTEMS Gastrointestinal
□ yes □ no Pain/burning with urination □ yes □ no Sores
□ yes □ no Constipation □ yes □ no Frequent urination □ yes □ no Bumps □ yes □ no Diarrhea
□ yes □ no Have you urinated in the past hour □ yes □ no Vaginal odor
□ yes □ no Discharge, If yes, color:________________
Have you or your partner(s) traveled more than 50 miles from the clinic? yes no Does anything make your symptoms better? yes no If yes, what?_______________________________________ Have you recently taken antibiotics? yes no If yes, when? ___________________ If yes, for what? ____________________ If yes, what kind?____________________________
To the best of my knowledge the above information is complete and correct. Patient Signature ____________________________________________________ Date _______/_______/________
Staff notes: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Time: Face to Face:_________ Counseling __________ Staff Signature: ______________________________________________________ Date _______/_______/________
Victorians 8a : Victorian Britain 8a : Britain since 1930 (WW2) 8b : History of Britain in its European and wider world 11b : A study of the impact of the Second World War on the lives of men, women and children from different 11a : A study of the impact of significant individuals, events and changes in work and transport on the lives of 7a : Study maps at a range of scales.
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