Sexually Transmitted Infection (STI) symptoms - {{first name}} {{surname}}

General Information

First Name

Surname

Date of Birth

Email Address

Home Phone

Mobile Phone

Home Address

Medicare Card Number - IRN *

How did you find out about us?

Emergency Contact Information

Emergency contact

Phone

Emergency contact’s relationship to you

Work Information

Current work status

EmployedRetiredNot workingLight Duty

Occupation

What symptoms do you currently have?

Abnormal discharge from the penis/vagina/rectum

Discomfort during sexual intercourse

Discomfort when passing urine

Genital area irritation

Blisters/Ulcers in the genital area

Unexplained rashes on the body

Pain in the pelvic region

Fever/chills

Nausea/vomiting

Specifics

Multiple sexual partners in the past year

New sexual partner recently

Unprotected sexual intercourse

Previous STI diagnosis

Partner with a diagnosed STI

Partner experiencing STI symptoms

History of intravenous drug use

Additional Information

Oral sex

Anal sex

Vaginal sex

Pregnant or planning to become pregnant

Received the HPV vaccine

Male who had sex with male (MSM)

Medical Background

Please list all medical conditions (e.g. High Blood Pressure, Asthma, Diabetes etc.)

Please list any medications you are currently taking.

Medications (Include Name, Dose, Frequency)

Please list any allergies.

Allergy

Please list any surgeries.

Surgery

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

Please upload any additional information.

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Consent

I confirm that the above information I have provided is true, complete and accurate. I agree to be contacted by a health professional via telehealth. *

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