STI and Prep – Huisartsen Valeriusplein

STIs en PrEP

Are you afraid you might have an STI? Do you have symptoms that could indicate an STI? Did you just hear that your sexual partner has an STI? Or are you in a new relationship? Fill out the questionnaire below and email/e-consult back to us; we will contact you for the next steps.

Information: www.soaaids.nl

We also offer PrEP treatment. For more information, please send an e-consult to Melissa.

STI Questionnaire

This questionnaire contains a number of intimate questions about your sex life and sexuality. These are necessary to determine as accurately as possible which tests are appropriate for you.

Personal data

Name

Date of birth

Gender

Man Woman Non-binary / I’d rather not say

E-mail

Telephone

Questionnaire

What is the reason you want an STI test?

Do you have any symptoms? If so, what are your symptoms? (e.g. pain or burning sensation when urinating, frequent urination, discharge from the penis or vagina, blisters, warts or sores around the genitals or anus, pain during intercourse, or irregular or abnormal bleeding (= between periods or during intercourse))?

Does your sexual partner have any symptoms? If so, what are those symptoms?

Have you had unprotected sex in the past six months?

no sex without a condom condom torn / slipped off

In what way did you have unsafe sex?

oral contact genital contact anal contact

Regarding oral contact: are there throat complaints? If so, since when?

How long ago did the last unsafe sexual contact take place?

Have you had sex with more than 3 different people in the past six months?

yes no

In the last half year have you had sexual contact with

men women both men and women?

Have you ever had an STI?

yes no

If so, which one? When?

And has this STI been treated?

Have your sexual partner(s) had an STI?

yes no

If so, which one? When?

And has this STI been treated?

Which country are you from?

From which country does/do your sex partner(s) come?

Have you had sexual contact for payment?

yes no

And your sex partner?

yes no

Have you used drugs by injection?

yes no

And your sex partner?

yes no

Have you been vaccinated against Hepatitis B?

yes no

Could there be a pregnancy?

yes no

Are there any other things I haven't asked but should know?

Space for any comments

Note: The costs of the STI test, like other laboratory costs, are deducted from your eigen risico!

BIG number:

Working days:

STIs en PrEP

STI Questionnaire

Personal data

Questionnaire

Links

Opening hours

STIs en PrEP

STI Questionnaire

Personal data

Questionnaire

Dr. Don Joeff

Dr. Don Joedfsd

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