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Today's date: / / How did you hear about us? (Check all that apply) Friend/family/word of mouth Return patient Doctor or medical provider City Website DIS/clinic staff Facebook Sex partner Outreach
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How to fill out std clinic demographic form
How to fill out std clinic demographic form
01
Start by writing your personal information, such as your full name, date of birth, and contact details.
02
Provide your address, including the street name, city, state, and zip code.
03
Indicate your gender and marital status.
04
Specify your ethnicity and race.
05
Fill in your medical history, including any past or current medical conditions, allergies, and surgeries.
06
Mention your sexual history, including the number of sexual partners, any history of sexually transmitted infections (STIs), and contraception methods used.
07
Answer questions related to your sexual orientation and gender identity.
08
Provide information about your sexual or reproductive health concerns or reasons for visiting the STD clinic.
09
Sign and date the form to confirm the accuracy of the provided information.
Who needs std clinic demographic form?
01
Any individual seeking services or consultation at an STD clinic needs to fill out the clinic demographic form.
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