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.

First Name

Date of Birth

Last Name

Preferred Name

Preferred Pronouns

She/Her

He/Him

They/Them

Other

General Health History

List all allergies to medications:

List any medications/vitamins/herbs/supplements you are taking:

Gender of You and Your Sexual Partners:

What was your gender at birth:

What is your gender today:

What sexual parts do you have?

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

Male

Female

Trans

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

Male

Female

Trans

Sexual History

Number of sex partners in last 3 months:

When was the last time you had sex?

In the last 12 months, how often have you used condoms for vaginal and anal sex?

Does anyone you have sex with have an infection or symptoms?

Do you use sex toys?

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

Oral

Anal

Vaginal

Were any of these new sex partners?

Did you use a condom?

Have you had sex with anyone who is HIV+ in the last 12 months?

Does anyone you have sex with inject drugs?

Do you share sex toys?

If you participate in anal sex, are you...

Infection History

Date of last HIV test:

Date of last test for other sexually transmitted infections:

If You Have a Cervix and/or Uterus:

When was the first day of your last menstrual period?

Date of last PAP Smear:

What do you currently do/use to prevent pregnancy?

Number of Pregnancies:

PAP Result:

Are you interested in starting birth control today?

Substance Use

Do you drink alcohol?

Number of drinks per week:

Have you ever injected drugs?

Have you injected in the last 12 months?

Have you ever shared needles with another person?

I have read and understand the WeARE HIPAA policy (see above)

SIGNATURE:

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Health History Form

General Inquiry