Sti Screening History Form - Planned Parenthood Of Maryland
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Client’s Name: _____________________________
DOB: ________________ Date: ________________
STI Screening History
Some of these questions are personal, but they help us in evaluating your health.
Age: _________
First day of your last period: ____________
Was it normal?
Yes
No
Yes
No MEDICAL HISTORY
Are you allergic to:
latex
medication (please list) ________________________
Are you taking any medications (drugs, vitamins, over the counter medication, and herbal medication)?
If yes, please list: _________________________________
Have you received the Hepatitis B vaccine?
shot 1
shot 2
shot 3
Yes No
SOCIAL HISTORY
Do you drink alcohol (beer, wine, liquor) – ____ drinks per week
Do you or your partner use street or IV drugs?
Yes
No FAMILY PLANNING HISTORY
Do you or your partner use birth control now?
If so, what? ______________________ *
If no method, why not?
trying to get pregnant
partner(s) is same sex
other_____________________
Yes No
SEXUAL HISTORY
Are you sexually active now? Check all that apply.
Vaginal
Anal
Oral
Date of last sex?___________
Have you ever had a sexually transmitted infection? If so, please check:
Chlamydia
Gonorrhea
Genital Warts
Hepatitis B or C
Herpes
HIV
Syphilis
Trichomoniasis
Other ____________
Has your partner been treated for a sexually transmitted infection? If yes, which one? _____________________
Do you think that you might have been exposed to a sexually transmitted infection?
Do you have sex with men who have sex with men?
Are you a man who has sex with men?
Have you ever exchanged sex for drugs or money or something you needed?
Have you had an anonymous sex partner recently?
# of partners you have had in past 3 months? ________12 months? _______ Partners are:
Male
Female
Both
Trans
How do you protect yourself from sexually transmitted infections?______________________________________
Relationship and Safety
Violence and sexual abuse are common in many people’s lives. There is help for you if you are being hurt or abused.
(Note: PPM is required to report cases of child abuse or neglect that occurred as a minor, even if you are now over age 18.)
NEVER
SOMETIMES
OFTEN
DECLINE
Has your partner ever tried to get you pregnant when you didn’t
want to be?
Does your partner refuse to use condoms when you ask?
Are you afraid your partner will hurt you?
Have you ever been physically or emotionally abused by your
partner or someone important to you?
Have you been hit, slapped kicked or otherwise physically hurt
by someone in the past year or, if you’re pregnant since you’ve
been pregnant?
Has anyone forced you to have sex in the past year?
Yes
No
Are you under the age of 18 and are your parent(s)/guardian(s) aware of your visit to Planned Parenthood of
Maryland?
CLIENT SIGNATURE
TO THE BEST OF MY KNOWLEDGE, THIS INFORMATION IS COMPLETE AND CORRECT.
X__________________________________________________________ Date:____________________
* If appropriate, recommend that client RTC for Hope visit or Limited Services visit.
PPMPF 172
Page 1 of 2
Rev: 10/2013
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