STD screening / infection (female)
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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Last name *
Date of birth *
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When did your last menstrual period end? If you do not have regular periods, enter "I do not have regular periods."
Example: My last period ended around June 16th
Is there any chance you could be pregnant?
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Do you engage in sexual intercourse with men, women, or both?
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Do you have a known exposure to any of the following? (check all that apply) *
Required
Vaginal discharge - If you have a vaginal discharge, please tell me the color, consistency (thick or watery), and whether it is malodorous. If you do not have a discharge, enter "None."
Example: I have a watery, brown discharge that smells bad
Do you have pelvic pain?
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Have you had any abnormal vaginal bleeding?
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Does it burn when you urinate?
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Are you urinating more frequently than usual?
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Do you have any genital sores, ulcers, masses, or other lesions?
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Have you had any unusual rashes on your palms or soles of your feet?
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Is there any particular testing that you are requesting? (check all that apply)
Is there anything else that you would like me to know?
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