Sexual Wellness Eligability Questionnaire-OLD
First Name
Last Name
Date of Birth
MM slash DD slash YYYY
Gender
Male
Female
Are you aged 18 plus?
(e.g. unusual discharge, pain or discomfort during intercourse or urination, sores, rashes, or itching in the genital area, bleeding during intercourse or urination)
Yes
No
Are you currently experiencing any symptoms?
(Required)
(e.g. unusual discharge, pain or discomfort during intercourse or urination, sores, rashes, or itching in the genital area, bleeding during intercourse or urination)
Yes
No
Has your sexual partner recently tested positive for a sexually transmitted infection (STI) or experience any symptoms?
(Required)
Yes
No
Has your sexual partner recently tested positive for a sexually transmitted infection (STI) or experience any symptoms?
(Required)
Yes
No