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 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?

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

Oral

Anal

Vaginal

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:

Substance Use

Number of drinks per week:

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

SIGNATURE:

Thanks for submitting!

General Inquiry