Date of Birth / Age / First Name(s)
(Likes to be called……………………...…....) / Surname
Title: Miss, Mrs, Ms (please circle) / Maiden name
Address:
Post Code:
Have you been to a sexual health clinic in Gloucestershire before? Yes / No
I describe my gender as follows:
Female ¨ / Transgender/non binary ¨
Male to Female ¨ Female to Male ¨
I describe my ethnic origin as follows:
Asian or Asian British
¨ Bangladeshi
¨ Indian
¨ Pakistani
¨ Chinese
¨ Any other Asian background
Black or Black British
¨ African
¨ Caribbean
¨ Any other Black background / Mixed
¨ White & Asian
¨ White & Black African
¨ White & Black Caribbean
¨ Any other mixed background
White
¨ British
¨ Irish
¨ Any other White background
¨ Eastern European / Other Ethnic Group
¨ Any other ethnic group
Country of Birth (please state)
………………………………….

PLEASE TURN OVER

About this visit
Was this your preferred clinic Yes ¨ No ¨ Comment………………………………………………………………………..
How quickly were you able to get an appointment or attend a walk-in?
Within 2 working days ¨
Over 2 normal working days ¨
Over a week but less than 2 weeks ¨
Over 2 weeks ¨
I was asked to attend by:
GP ¨ Chlamydia screening programme ¨ Sexual Assault Referral Centre (SARC) ¨ HIV service ¨
Self-referred ¨ Other ……………………………………
Your contact details – please enter numbers and also tick the boxes of your two preferred contact methods
Mobile Telephone Number: ¨ / Occupation
Work Telephone Number: ¨ / GP’s name and address
Is it ok to contact your GP? Yes / No*
*We will contact your GP if you have a positive STI result and do not reply to your chosen contact methods for results
Home Telephone Number ¨
Letter to home address: ¨
Is it OK to text? Yes/No
Is it OK to leave voicemail? Yes/No

SEXUAL HEALTH TRIAGE FORM

The information you provide below will help us to provide you with the most appropriate appointment for your problem. The information you provide will be kept confidential and will be seen only by the clinical staff.

PLEASE TICK ALL THAT APPLY
No Worries (I have no symptoms) I just want a sexual health screen ¨
I am worried about symptoms (please tick all below that apply)
Unusual vaginal discharge ¨ Lumps, spots, rash on genitals ¨
Tummy pain/ pain during or after sex ¨ Pain/discomfort/problems when passing urine ¨
Unusual vaginal bleeding/Bleeding during or after sex or Itching in genital area ¨
change to periods ¨ Discharge/pain/bleeding from bottom ¨
Painful blisters, sores and ulcers on genitals ¨
Rash over body¨ arms¨ legs¨soles¨ palms ¨ Other (please specify) ………………………………
I want (please tick all below that apply)
To start contraception ¨ A follow up appointment ¨
A repeat issue of depo injection or pill ¨ An HIV test ¨
Pregnancy advice/Pregnancy test ¨ Advice/Help following a sexual assault ¨
A Smear test ¨ for age 25 & over and must be due
Advice/ Emergency contraception as I have had unprotected sex in last 12 hrs¨ 24 hrs ¨ 48 hrs¨ +48hrs ¨
Advice/Treatment as I have been in contact with an infection ¨
Advice/PEPSE Treatment as I have been exposed to HIV infection in the last 72 hours ¨
Other (please specify) ………………………………………………………………………………………………………..
Coil (IUS/IUD) insertion ¨ change ¨ removal ¨ check ¨
Implant insertion ¨ change ¨ removal ¨

I confirm the above details are correct.

Name: ……………………………………….. Signature …………………………….. …………..

Date of Birth………………Age ……………….Date……………………….. Time of arrival…………..

‘Please note that any contact details you provide may be used by Gloucestershire Care Services NHS Trust to communicate information about your care with you. We cannot guarantee for the security of the information contacted in such communications once this travels outside of the security of our systems. If you receive a text/email in error then any distribution, copying or use of this communication of the information in it is strictly prohibited. Please notify the sender and delete all copies. Thank you’

FOR STAFF USE ONLY
AGREED TRIAGE ACTION PLAN
Signature …………………………….. Date……………………….. Time ………………………