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Download INTEGRATED SEXUAL HEALTH SERVICES In order to ensure you
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INTEGRATED SEXUAL HEALTH SERVICES Patient Label In order to ensure you see the correct member of staff, please answer the following questions as accurately as possible. Yes No You are under 18? You have concerns/questions you wish to discuss? You have one of the following problems Pain when passing urine discharge? Vaginal/penile discharge or discomfort? Any new sexual partners within the last 2 weeks? Have you taken any antibiotics within the last 2 weeks? You have lumps or spots or rash in the genital area? Are you attending because of a sexual assault? You are a current or previous intravenous drug user, or you have a partner that injects drugs? In the last 6 months or since your last visit you have been in contact with the following infection: Gonorrhoea Chlamydia HIV Syphilis Hepatitis B or C You currently or have previously worked in the sex industry, adult film industry or had sex with anybody that works in these industries? You or your partners were born in South America, Asia, Africa or Eastern Europe? You have same-sex partners? Women only You are pregnant and are experiencing the following, abnormal bleeding, discharge or abdominal pain? Do you want advice regarding your pregnancy? You need emergency contraception? Abdominal pain recent (in the last month) and getting worse? Abnormal bleeding e.g bleeding after sex/bleeding in-between periods? You want to discuss contraception? Men only Testicular pain recent (in the last week) and getting worse? Testicular swelling, lumps? You last passed urine less than one hour ago? PTO R INTEGRATED SEXUAL HEALTH SERVICES Patient Label IMPORTANT If you answered NO to all of the questions, you do not need to see a doctor or nurse. This would mean you could have all of your tests taken by a trained support worker which is quicker. Please sign below if you are happy to have tests without speaking to a doctor or nurse. I am willing to be seen by a trained Support Worker for tests (HIV, Syphilis bloods test and tests for Chlamydia and Gonorrhoea). I understand I will not be able to talk to a Doctor or Nurse. Please circle YES / NO Patient’s Name…………………………………………………….....…………. Signature....................................................................................................... Date............................................................................................................... Are you happy to receive results in a text message? YES / NO Mobile number............................................................................................... FOR OFFICIAL USE ONLY Tests taken: If Results NEGATIVE CT/GC VVS swab/urine Please Tick As Appropriate HIV/STS blood Condoms D2B D3 DISCHARGE Name/Designation/Signature ................................................................................ (As no follow up planned within next 6 weeks) Date............................... Results negative OK to text (Date) (Initials) Text sent (Date) (Initials)
