Sexual health consultation

[+] yes, present, positive
[-] no, absent, negative
[~] equivocal
[\] not performed, not applicable
[?] unknown, unsure
# comment

PRESENTING COMPLAINTS OR ISSUES
Reasons for visit:
- Sexual health consultation

Reason for presenting:
[-] questions/concerns 
[-] symptoms 
[-] STI contact 
[-] STI preventive health check

[STI risk assessment]

(5 Ps: partners, prevention of pregnancy, protection from STIs, practices, and past history of STIs)

1. Partners: (current or past sexual activity)
  Last activity: 
  Gender/s of partner/s[?] (M F Both): 
  Number of different partners in the last 6 months:

2. Practices: (kinds of sexual activity [-] now and past)
[-] receptive oral sex (mouth on penis/vagina)
[-] insertive oral sex (mouth on penis/vagina)
[-] vaginal sex (penis in vagina)
[-] receptive anal sex (penis in rectum/anus)
[-] insertive anal sex (penis in rectum/anus)

3. Protection from STIs: 
[-] consistent condom use
[-] HIV PrEP 
[-] DoxyPrEP
[-] regular STI testing
[-] discussion with partners about STI prevention

4. Prevention of pregnancy (if applicable):
[-] Current use of contraception/birth control [-] type -> 
[-] Partner/s current use of contraception/birth control [-] type ->

5. Past history of STIs:
[-] previous testing for STIs and HIV
[-] previous diagnosis of STI [-] diagnosis/es -> 
[?] any partner/s diagnosed with an STI [-] type/s ->

6. Other HIV and viral hepatitis risk:
[-] you or any partner/s use injected drugs

IMMUNISATIONS
Immunisation history:
[?] Hepatitis A
[?] Hepatitis B
[?] HPV

PHYSICAL EXAMINATION
External genitalia: 
-

ASSESSMENT
Clinical summary:
[+] 
[?] 
[-]

Problems and issues:
[+] 
[-]

Diagnosis/es:
[+] 
[-]

Differential diagnosis:
[+] 
[-]

MANAGEMENT PLAN
Diagnostic investigations requested:
Key: [+] ordered, [-] not ordered; [x] recommended but declined

[-] Chlamydia NAAT PCR
  [-] Genital swab (preferred for women)
  [-] Urine^
  [-] Rectal swab (receptive anal sex)
[-] Gonorrhoea NAAT PCR
  [-] Genital swab (preferred for women)
  [-] Urine^
  [-] Oropharyngeal swab (oral sex)
  [-] Rectal swab (receptive anal sex)
[-] HSV PCR swab (symptomatic lesions)
[-] HIV serology (Ab/Ag)
[+] Syphilis serology
[-] Hepatitis A serology (MSM)
[+] Hepatitis B serology (HBsAg)
[+] Hepatitis C serology (HepCAb)
[-] Trichomonas NAAT PCR urine^ (at risk, eg ATSI people)
[-] Mycoplasma genitalium (persistent and recurrent non-gonococcal urethritis, cervicitis, pelvic inflammatory disease, post-coital bleeding, known sexual contact).

^First catch urine, any time of the day, > 20 minutes since last urination.

Information and advice given:
-

Medication:
-

FOLLOW-UP
Next appointment:
-

Outstanding issues:
-

[dqref.com 250127]

Sexual health consultation

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