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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

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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