STI Test BVD

STI Rapid Diagnostic Test Screening Form
FREE Rapid STI Tests are by appointment. You will be asked to schedule your appointment at the end of this form.

Appointments must be booked at least 5 minutes in advance.

Test You Wish to Take

GonorrheaChlamydiaTrichomonasHIV 1 and 2HCVSyphilis
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Sex at Birth*

MaleFemale
Sexual Orientation
Preferred Pronouns
Race/Ethnicity*

Caucasian/WhiteAfrican AmericanHispanicAsianAmerican IndianPacific IslanderOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address
example@example.com
Primary Care Provider
Primary Care Provider (PCP) Name*

First NameLast Name
Primary Care Provider (PCP) Phone Number
Please enter a valid phone number.
Primary Care Provider (PCP Fax Number
Please enter a valid phone number.
Please List Medications and/or Supplements You Are Taking *
Please List Patient Health History*
Do You Have Any Medication or Drug Allergies*

YesNo
If Answered "Yes" Above, Please List Known Allergies Below AND What Type or Reaction You Had*
Sexual Partners*

MaleFemaleNon-BinaryOther
Relationship Type*

MonogamousNon-MonogamousPrefer Not to Answer
Reason for Testing*
Please Select Below If Any of the Following Apply to You*

Pregnant or planning to become pregnantImmunocompromisedSharp lower abdominal painNone of the above
Current Symptoms

For Patients: The following questions will help us determine the severity of your illness and recommendations we can make. If a question is not clear, please ask us to explain it.
Please Check All of the Symptoms That Apply to You*

Genital Secretions (Vaginal)Genital Secretions (Penile)Fever >100.4°FBurning/itchingGenital WartsYellowing of SkinAbnormal BleedingFatigueDark UrineRedness or Discoloring of GenitalsTender or Sensitive GenitalsBody SoresOther
Brief Description of Symptoms*
Consent to Testing
I have read, or have had read to me, the written information regarding the diagnostic test being administered. By signing below, I signify that I agree to allow those pharmacists affiliated with the pharmacy named above to administer the tests for STIs. I understand that the tests being provided to me today are through a grant and do not quantee that there will be no charge for tests in the future. This assessment does not constitue a medical diagnosis. Negative results do not preclude infection and should not be used as the sole basis for treatment. I understand the test that I am receiving is a rapid diagnostic test using antigens or rapid PCR tests. Antigen tests look for viral proteins, which are highly specific, meaning that if you test positive, you are very likely infected. However, there is a higher chance of false negative with antigen tests, which means that a negative result cannot definitively rule out an active infection. If you have a negative result on an antigen test but have a recent exposure, or are displaying many of the symptoms, you may wish to follow up with a more accurate test at another clinic to confirm the results. I have had the opportunity to ask questions that were answered to my satisfaction. I certify that I am at least 18 years old and hereby give my consent to the pharmacists of this Pharmacy to administer the STI diagnostic tests. I understand that by signing below I am responsible for following up with another provider if refered onto by the pharmacist.
I understand if my results are positive, I should follow-up with my Primary Care Provider.*

Yes
Form completed by*

First NameLast Name
Signature of Person Receiving the Diagnostic Test (Or Parent/Guardian if Patient is *

Clear
Pharmacy Use Only

Do not complete the below questions
Name / NPI Pharmacist (Signature)

Lucas Smith, 1609283837Lauren Gover, 1205345865Anthony Urban
Temperature (F)*
Scoring

Sore Throat (1 point)Fever >100.4 F (1 point)Runny/Stuffy Nose (1 point)Muscle Aches (1 point)Cough (1 point)
Score

(0-1) Flu test & antibiotic therapy are not indicated(2-3) Flu test indicated(4 or greater) Consider antiviral therapy
Status Flu Test Results*

POSITIVENEGATIVE
Status Flu Test Lot*
Status Flu Test Exp*
BP
Pulse
Pharmacotherapy Plan
Initiate Antiviral Therapy

YESNOOther: ____________________
Supportive Care Recommended by Pharmacist

Fluids (water, Gatorade, Pedialyte, etc)Tylenol 325mg (1 - 2 tablets every 4-6 hours), Ibuprofen 200mg (1 tablet every 4-6 hours), Naproxen 220mg (1 tablet every 12 hours)Warm saltwater gargleThroat lozenge/cough cropOther:________________________________
Pharmacist Follow-Up in 48 hours

Date:_____________________ Pharmacits:___________________________
Should be Empty:

STI Rapid Diagnostic Test Screening Form

Primary Care Provider

Current Symptoms

Consent to Testing

Pharmacy Use Only

Pharmacotherapy Plan