Sexually Transmitted Infection Form
Patient Information
Name
First Name
Last Name
Height
Weight
Age
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
Country
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical History
Currently Pregnant?
Yes
No
Currently Due Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Last Menstrual Cycle
Lenghth of Cycle
Birth Control Method
Marital Status
Symptoms
Cloudy/Bloody Discharge
Yellow/Green Discharge
Painful Urination
Painful/Swollen Testicles
Painful Bowel Movements
Painful Intercourse
Strong Vaginal Odor
Vaginal Itching/Irritation
Penile Itching/Irritation
Anal Itching
Abnormal Menstruation
Testicular Pain
Fever
Aching Joints
Weight Loss
Abdominal Pain
Painful Sores
Non-Painful Sores
Sore Throat
Headache
Rash
Swollen Lymph Nodes
Fatigue
Diarrhea
Other Sympto
Symptom(s) Start Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Symptom Fruquency
Constant
Regular
infrequent
Irregular
Specimen Source
Rectum
Genitalia
Urethra
Cervix
Throat
Blood
Lesion
Diagnosis
Type a question
Syphilis
Chlamydia
Gonorrhea
Trichomoniasis
HPV
HIV
Genital Herpes
Pubic Lice
Chancroid
Scabies
Hepatitis
Other
Physician Information
Name
First Name
Last Name
Date Reported
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Physician Notes
Signature
Submit
Should be Empty: