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Health History Form

Please fill out the following form prior to your appointment.

This form is not a part of your permanent record and will be destroyed following your visit today for confidentiality

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By filling out the form below, you acknowledge that you have read and understand our HIPAA/Privacy form and our Telehealth Services policy.

Preferred Pronouns

General Health History

Gender of You and Your Sexual Partners:

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What gender are the people you have had sex with in the last 3 months?
What gender are the people you have had sex with in the last 12 months?

Sexual History

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What types of sex do you participate in? (choose all that apply)
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Infection History

What sexually transmitted infections have YOU had in the past?

If You Have a Cervix and/or Uterus:

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Substance Use

Types of tobacco used:
Which of these drugs have you used in the last 12 months?
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Thanks for submitting!

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