Microsoft word - sti vaginitis medical visit 10-2012
This medical record is confidential and will not be released to anyone except as may be required by law.
St. Croix County DHHS-Public Health Dept.
1445 N 4th Street, New Richmond, WI 54017
Name _____________________________________________________ Date of Birth ___________________ Age _____________ Last First M Reason for visit: ____________________________________________ Phone # to contact you: _______________________________ Please check if you are allergic to: No Allergies Penicillin
List medications, vitamins, over the counter drugs, and/or herbs you take:_____________________________________________________
MENSTRUAL HISTORY Day last period began:____________________ Was it normal? yes no Have you had sex since your period? yes no CONTRACEPTIVE HISTORY Are you using a method of birth control now? yes no If yes, what kind? _____________________________ Do you use condoms? yes no sometimes SEXUAL HISTORY Have you had more than one sexual partner in your lifetime? yes no Check if you have: vaginal sex oral sex anal sex sex with men sex with women sex with both Check if your partner(s) have: vaginal sex oral sex anal sex sex with men sex with women sex with both Have you had a new partner or more than one partner in the last 90 days? yes no don’t know Has your partner(s) had a new sex partner or more than one partner in the last 90 days? yes no don’t know Have you had symptoms or a diagnosis of an STI in the last 90 days? yes no don’t know Has your partner(s) had symptoms or a diagnosis of an STI in the last 90 days? yes no don’t know Have you or your partner(s) used IV drugs? yes no don’t know Have you ever had? Chlamydia Gonorrhea HPV/warts Herpes Syphilis Have you had Chlamydia in the last 5 years? yes no REVIEW OF SYSTEMS Gastrointestinal
□ yes □ no Pain/burning with urination □ yes □ no Sores
□ yes □ no Constipation □ yes □ no Frequent urination □ yes □ no Bumps □ yes □ no Diarrhea
□ yes □ no Have you urinated in the past hour □ yes □ no Vaginal odor
□ yes □ no Discharge, If yes, color:________________
Have you or your partner(s) traveled more than 50 miles from the clinic? yes no Does anything make your symptoms better? yes no If yes, what?_______________________________________ Have you recently taken antibiotics? yes no If yes, when? ___________________ If yes, for what? ____________________ If yes, what kind?____________________________
To the best of my knowledge the above information is complete and correct. Patient Signature ____________________________________________________ Date _______/_______/________
Staff notes: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Time: Face to Face:_________ Counseling __________ Staff Signature: ______________________________________________________ Date _______/_______/________
DIE FILES DÜRFEN NUR FÜR DEN EIGENEN GEBRAUCH BENUTZT WERDEN. DAS COPYRIGHT LIEGT BEIM JEWEILIGEN AUTOR. COMER: WICHTIGE NAMEN UND MODELLE, KAPITEL 1-10 Somatogene Sichtweise: Emil Kraeplin (vs. psychogene Sichtweise u.a. mit Hypnose, Josef Breuer)) Deinstitutionalisierung und gemeindepsychiatrischer Ansatz Gehirn, synaptischer Spalt, Neurotransmitter Pawlow, Watson, Thornd
CILT’s Volunteer Vibes Volume 6 Issue 2 September 2004 Welcome New Volunteers We are fortunate in that we have had a number of fantastic additions to ourvolunteer team. Please join me in welcoming Suzanne Curran, Debra Hunt and Rita Grotsky to CILT. We are very pleased to have them working with us. Thinking About Today’s Older Adult Volunteer Excerpted from "Why Volunteer?