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STD screening / infection (male)
Texas Telemedicine Doctor
Use this form if you would like to be screened for an STD or if you think you have an STD. If you have been diagnosed with genital herpes in the past and want to be seen for that, please use the genital herpes form.
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* Indicates required question
Last name
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
Do you engage in sexual intercourse with women, men, or both?
Women
Men
Men and women
Clear selection
Do you have a known exposure to any of the following? (check all that apply)
*
Gonorrhea
Chlamydia
Syphilis
HIV
Herpes
Hepatitis C
Hepatitis B
No. I have not been told by a partner that I was exposed to anything.
Required
Do you have any penile (urethral) discharge?
Yes
No
Clear selection
Does it burn when you urinate?
Yes
No
Clear selection
Are you urinating more frequently than usual?
Yes
No
Clear selection
Do you have any genital sores, ulcers, masses, or other lesions?
Yes
No
Other:
Clear selection
Have you had any unusual rashes on your palms or soles of your feet?
Yes
No
Clear selection
Is there any particular testing that you are requesting? (check all that apply)
Gonorrhea
Chlamydia
Syphilis
HIV
Herpes
Hepatitis C
Hepatitis B
Other:
Is there anything else that you would like me to know?
Your answer
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