Pre-consultation: STI Testing

First name *

Last name *

Email *

Phone *

Date of birth *

Why are you attending for STI testing? *

Routine screening - no symptoms

Symptoms - need testing

Partner diagnosed with STI

Post-exposure check

New relationship check

Occupational exposure

Gender of sexual partners in last 12 months *

Men

Women

Both

Prefer not to say

Number of sexual partners in last 3 months *

0

1

2-5

6-10

More than 10

Number of sexual partners in last 12 months *

0

1

2-5

6-10

11-20

More than 20

Condom use during sexual contact *

Always

Usually

Sometimes

Rarely

Never

Types of sexual contact in last 3 months *

Testing sites depend on sexual practices - helps determine where to swab

Receptive anal

Insertive anal

Receptive vaginal

Insertive vaginal

Receptive oral

Insertive oral

Last sexual contact was *

Some tests need minimum time since exposure: chlamydia/gonorrhoea 5+ days, syphilis 3-6 weeks, HIV 2-6 weeks

Within 24 hours

1-7 days

1-4 weeks

1-3 months

More than 3 months

New sexual partner in last 3 months? *

Yes

No

Do you have any genital symptoms? *

Yes

No

Do you have a uterus / menstruate?

Yes

No

Prefer not to say

Have you previously been diagnosed with an STI? *

Yes

No

Not sure

What was tested at your last STI test?

Last HIV test *

Never tested

Within 3 months

3-6 months ago

6-12 months ago

More than 12 months ago

HIV status *

Negative

Positive - on treatment

Positive - not on treatment

Never tested

Don't know

Specific HIV risk factors

Condomless anal sex

Partner with HIV (status known)

Multiple partners

IV drug use

Sex work

Occupational exposure

None identified

Are you on PrEP?

Yes

No

Considering it

Not applicable

Hepatitis B vaccination status *

Fully vaccinated

Partially vaccinated

Not vaccinated

Not sure

Have you been tested for Hepatitis B?

Yes - negative

Yes - positive

No

Not sure

Have you been tested for Hepatitis C?

Yes - negative

Yes - positive

No

Not sure

HPV vaccination status

Yes - full course

Yes - partial course

No

Not sure

Not eligible at time

Does alcohol use ever affect your sexual decisions?

Yes

No

Rarely

Prefer not to say

Use recreational drugs during sexual activity (chemsex)?

Yes

No

Occasionally

Prefer not to say

Do you inject drugs?

Yes

No

Previously did

Prefer not to say

Do you have any antibiotic allergies? *

Yes

No

Not sure

All current medications *

Recent antibiotics in last 4 weeks?

Recent antibiotics may affect test results

Yes

No

Has a partner been diagnosed with an STI and asked you to get tested?

Yes

No

Not sure

Are you able to notify your sexual partners if a result is positive?

Yes, all of them

Yes, some of them

No

Prefer not to

Need help with this

Which tests would you like? *

Full sexual health screen

Specific test only

Comprehensive blood panel

Recommend what's needed

Your goals for this visit

STI screening

Treatment for symptoms

Partner notification

PrEP assessment

Hepatitis vaccination

General sexual health advice

Other

Preferred consultation format *

Physical examination may be needed for symptoms

Face to face

Video

Phone

Anything else we should know?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

STI Testing

Why are you attending for STI testing? -

Sexual History

Gender of sexual partners in last 12 months -

Number of sexual partners in last 3 months -

Number of sexual partners in last 12 months -

Condom use during sexual contact -

Types of sexual contact in last 3 months -

Last sexual contact was -

New sexual partner in last 3 months? -

Current Symptoms

Do you have any genital symptoms? -

Menstrual & Pregnancy

Do you have a uterus / menstruate? -

STI History

Have you previously been diagnosed with an STI? -

What was tested at your last STI test? -

HIV Assessment

Last HIV test -

HIV status -

Specific HIV risk factors -

Are you on PrEP? -

Hepatitis & Vaccination

Hepatitis B vaccination status -

Have you been tested for Hepatitis B? -

Have you been tested for Hepatitis C? -

HPV vaccination status -

Substance Use

Does alcohol use ever affect your sexual decisions? -

Use recreational drugs during sexual activity (chemsex)? -

Do you inject drugs? -

Allergies & Current Medications

Do you have any antibiotic allergies? -

All current medications -

Recent antibiotics in last 4 weeks? -

Contact Tracing & Support

Has a partner been diagnosed with an STI and asked you to get tested? -

Are you able to notify your sexual partners if a result is positive? -

Testing Preferences & Goals

Which tests would you like? -

Your goals for this visit -

Preferred consultation format -

Anything else we should know? -

Anything else for your doctor?