STI

Patient presents for STI exam. Reason for visit [text name="variable_1" default=""]

Number of partners over the past year: [text name="variable_44" default=""]
[checkbox name="variable_1" value="heterosexual|homosexual|bisexual"]

[checkbox name="variable_2" value="Penile discharge - None|Penile discharge - Clear|Penile discharge - Yellow"]
Condom used regularly [checkbox name="variable_12" value="Yes|No"]
[checkbox name="variable_3" value="dysuria -Yes|dysuria - no"]
[checkbox name="variable_4" value="Ulcer -yes|Ulcer- no"]
[checkbox name="variable_5" value="Rash - yes|Rash - no"]
[checkbox name="variable_6" value="Fever -yes|Fever - no"]
[checkbox name="variable_14" value="Testicular pain - yes|Testicular pain -no"]
[checkbox name="variable_15" value="Rectal or perinial pain - yes|Rectal or perinial pain -no"]

[checkbox name="variable_8" value="Pelvic Pain - yes|Pelvic Pain -no"]
[checkbox name="variable_9" value="Vaginal discharge|no Vaginal discharge"]


[checkbox name="variable_10" value="Std check in past- yes|Std check in past - no"][text name="variable_1" default=""]
[checkbox name="variable_13" value="Currently takes OCP |Pt has IUD|Not on birth control"]
[checkbox name="variable_14" value="Denies concerns about pregnancy|Unsure about pregnancy status"]

[textarea name="variable_15" default=""]