Wyoming Department Of Health - Communicable Disease Hiv, Hepatitis And Std Risk Assessment

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Wyoming Department of Health – Communicable Disease HIV, Hepatitis and STD Risk Assessment
FACILITY INFORMATION
Today’s Date: _______________________________
Facility Name: ______________________________
Facility Address: ____________________________
Facility Phone number: _______________________
Client ID: _________________________________
Client: Please complete pages one and two of this document. The following information will be helpful for your provider to
determine proper screening and/or vaccination needs for this visit.
DEMOGRAPHICS
Patient Name: __________________________________________________________ DOB: ____________ Age: __________
Address: _______________________________________________ City: ______________________________ Zip: __________
Phone: _______________________ Email: _____________________________________________________________________
Preferred Method of Contact by Clinic:
Phone
Email
Mail
Other:
_______________________________________
Contact Restrictions: _______________________________________________________________________________________
Race (check all that apply):
White
Black/African American
Native American/Alaskan Native
Asian
Don’t know
Native Hawaiian/Pacific Islander
Other
Decline to answer
Don’t know
Ethnicity:
Hispanic
Non-Hispanic
Decline to answer
Current Gender:
Male
Female
Transgender (male to female)
Transgender (female to male)
SEXUAL HEALTH AND HISTORY
Current gender of sex partner(s) and type of sex (check all that apply):
Male:
Oral (give/receive)
Anal (give/receive)
Vaginal
Transgender (male to female) :
Oral (give/receive)
Vaginal
Anal
Female :
Oral (give/receive)
Vaginal
Anal
Transgender (female to male):
Oral (give/receive)
Anal (give/receive)
Not currently sexually active
Please list the number of sexual partners you have had within the last 3 months:
Have you ever had an HIV test?
Yes, result and date: ______________________________________________________
No
Have you been vaccinated for Hepatitis B?
Yes, when?:____________________________________________________
No
Have you been vaccinated for Hepatitis A?
Yes, when? ____________________________________________________
No
Have you been vaccinated for HPV?
Yes, when? _________________________________________________________
No
Do you know if you have recently been exposed to any STDs, HIV or Viral Hepatitis?
Yes, specify disease and date: _________________________ (Contact type: Household/ needle share/ sexual/ blood
exposure)______________________________
No
Have you had a positive STD, HIV, or Viral Hepatitis test in the past 12 months?
Yes, specify disease and date:_________________________________________________________________________
No
Females:
Are you pregnant?
Yes, due date: ________________________________
Possibly
No
Unknown
Date of last pelvic exam/pap test: __________________________________________________________________
Unknown
Client Initials: _________________
June 23, 2016
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