STI Intake

1
Patient status
I am the patient
I am the patient's legal representative
2
Full name* This field is required.
3
Date of birth* This field is required.
4
Email* This field is required.
example@example.com
5
Primary phone number* This field is required.
6
Last 4 digits of Social Security Number* This field is required.
7
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Where does the patient currently reside?* This field is required.
Within Springfield city limits
Outside of Greene County
Greene County
9
Patient's race* This field is required.Please select all that apply.
American Indian/Alaska Native
Asian
Black/African American
Pacific Islander
White
Decline to respond
10
Patient's ethnicity* This field is required.
Hispanic/Latinx
Not Hispanic/Latinx
Decline to respond
11
What is the patient's preferred language?* This field is required.
12
Patient's sex assigned at birth* This field is required.
Male
Female
Decline to respond
13
Patient's current gender identity* This field is required.
Male
Female
Transgender male
Transgender female
Genderqueer
Decline to respond
14
Patient's gender pronouns* This field is required.
She/Her
He/Him
They/Them
Decline to respond
15
Patient's sexual orientation* This field is required.
Bisexual
Straight or Heterosexual
Lesbian, Gay or Homosexual
Unsure or questioning
Decline to respond
16
Patient's insurance status* This field is required.
Private or Employer Insurance
Medicare
Medicaid
Underinsured
Uninsured
Decline to respond
17
At this time is the patient unsheltered or homeless?* This field is required.
YESNO
18
Have you been seen at the Springfield-Greene County Health STI clinic in the last 3 months?* This field is required.
YESNO
19
You are not eligible for testing at this time.

Thank you for checking your elibility for STI testing at Springfield-Greene County Health. Unfortunately you are NOT eligible for testing at this time because it has been fewer than 3 months since your last visit with us. Please check back after your 3-month waiting period has passed.
20
Are you currently on any antibiotics prescribed by a healthcare provider?* This field is required.Medications such as Tylenol, Acetaminophen, Ibuprofen and Aspirin are NOT antibiotics.
YESNO
21
Were you prescribed antibiotics for acne?* This field is required.
Yes
No
I don't know
22
What antibiotic were you prescribed?* This field is required.Please select all that apply
Amoxicillin/Clavulanate (Augmentin) Amoxicillin (Novamox, Amoxil)
Ampicillin
Azithromycin (Zithromax)
Bacitracin
Cefazolin
Cefepime (Maxipime)
Cefixime (Suprax)
Ceftriaxone (Rocephin)
Cephalexin (Keflex)
Ciproflaxin (Cipro)
Clarithromycin (Biaxin)
Clindamycin (Cleocin)
Doxycycline
Erythromycin (Erythocin)
Gemifloxacin (Factive)
Gentamicin (Garamycin)
Isoniazid (INH)
Levofloxacin (Levaquin)
Linezolid (Zyvox)
Methicillin
Neomycin (Neo-Fradin)
Penicilin V or G
Piperacillin
Rifampicin (Rifampin)
Silver Sulfadiazine
Streptomycin
Tetracycline
Tobramycin (Nebcin)
Trimethoprim-Sulfamethoxazole (Bactrim) Vancomycin (Vancocin)
23
You are not eligible for testing at this time.

Thank you for checking your elibility for STI testing at Springfield-Greene County Health. Unfortunately you are NOT eligible for testing at this time because you have indicated you are currently on antibiotics prescribed by your healthcare provider. Antibiotics can interfere with our testing process and produce false results. Please check back after you have been off antibiotics for at least 4 weeks.

Please call 471-864-1672 with questions.
24
Are you a male that has sex with other men?* This field is required.
YESNO
25
Are you a male with discharge?* This field is required.
YESNO
26
Are you an individual who has been sexually assaulted?* This field is required.
YESNO
27
Would you like to see a nurse for counseling?* This field is required.
YESNO
28
Have you had sex with any men in the last three months?* This field is required.
YESNO
29
In the last 2 months, have your or a sexual partner tested positive for an STI?* This field is required.
YESNO
30
Can you verify your partner's positive results?* This field is required.Verification means you have a copy of their positive result or you know their name, date of birth and where they were tested.
YESNO
31
Please come in for evaluation.

Thank you for checking your eligibility for STI testing at Springfield-Greene County Health. Based on your responses, we recommend you visit with a nurse for evaluation and counseling. Appointments are not necessary for a nurse consultation. You may walk in to the Health Department, located at 227 E. Chestnut Expressway on Mondays or Wednesdays from 8:00 am-2:00 pm.

Please call 471-864-1672 with questions.
32
Which of the following symptoms do you have?* This field is required.Please select all that apply.
Back pain
Burning during urination
Cramping
Fatigue
Fever
Headache
Muscle aches
Swollen lymph nodes
None
33
Do you have any new or unexplained rashes on your body?* This field is required.Rashes may appear on the face, inside the mouth, hands, feet, chest, genitals or anus.
YESNO
34
Have you come into contact with anyone in the past 21 days that has a rash?* This field is required.
YESNO
35
Have you donated blood or plasma in the past 3 months?* This field is required.
YESNO
36
Have you participated in a medical research study in the last 3 months?* This field is required.
YESNO
37
Do you have sex with males?* This field is required.
YESNO
38
Do you have sex with females?* This field is required.
YESNO
39
Are you or your partner pregnant?* This field is required.
YESNO
40
Please select your test type* This field is required.Please select all that apply. Mycoplasma Genitalium testing will take place if you meet requirements.
Urine test for Chlamydia, Gonorrhea, Trichomonas and/or Mycoplasma Genitalium
Blood test for Syphillis and/or HIV
41
Emergency contactThis is optional.
Emergency contact name
Emergency phone number
42
Please select your testing time* This field is required.Appointments are available on Tuesdays, 12:15-3:00 pm. You may schedule up to 7 days in advance.
43
Your identity* This field is required.
I am the patient
I am the patient's legal representative
Springfield-Greene County Health staff member
44
What is your relationship to this patient?* This field is required.
45
Notice of Privacy Practices
46
Please explain why you refuse to acknowledge receipt or offer of this office's Notice of Privacy Practices.* This field is required.
47
Signature of patient or legal representative* This field is required.
Clear
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