Health History Form | WeARE | Advocates for Reproductive Education

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Advocates for Reproductive Education

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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.

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:

What sexually transmitted infections have YOU had in the past?

None

Gonorrhea

Chlamydia

Trichomonas

Herpes

HIV

Syphilis

Hepatitis B

Genital Warts

Molluscum

Urethritis (NGU)

Cervicitis (MPC)

HPV

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

Types of tobacco used:

None

Cigarettes

Chew/Snuff

Cigars

E-Cigs

Which of these drugs have you used in the last 12 months?

None

LSD

Marijuana

Meth

Cocaine/Crack

Heroin

Poppers

Ecstasy

Opiates

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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General Inquiry

First Name

Last Name

Email

Phone

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MAKE AN APPOINTMENT

Call: 218.454.1546

Text: 218.838.6280

CLINIC HOURS

Mon, Tues, Thurs

12:00 p.m. to 6:00 p.m.

615 Oak Street

Brainerd, MN 56401

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