Male STD Discharge Symptom Checker Questionnaire Form
Complete this questionnaire to help assess your symptoms. This form is for informational purposes only and does not collect sensitive personal data. Please answer as accurately as possible.
How old are you?
*
How long have you noticed the discharge?
*
Please Select
Less than 24 hours
1-3 days
4-7 days
More than a week
What is the color of the discharge?
*
Please Select
Clear
White
Yellow
Green
Bloody
Other
Is there any odor associated with the discharge?
*
No odor
Mild odor
Strong or unpleasant odor
Are you experiencing any of the following additional symptoms?
*
Burning during urination
Itching
Soreness or pain
Swelling
None of the above
Have you had any new sexual partners in the past 3 months?
*
Yes
No
Do you use protection (such as condoms) during sexual activity?
*
Always
Sometimes
Never
Have you had similar symptoms in the past?
*
Yes
No
Have you recently taken any antibiotics?
*
Yes
No
Please describe any other symptoms or relevant medical history.
Submit
Should be Empty: