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David Schechter, M.D.
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Appointment Request...call us if no response
Contact Us...call us if no response
HIPAA Consent
Medicare Beneficiary Private Contract
New Patient Demographics Form
Patient Health Questionnaire - Depression Screening
Review of Symptoms
Sexual Health Questionnaire
TMS Forms
Use of Health Insurance
Sexual Health Questionnaire
FULL NAME
*
First Last
DATE
*
Today's date
Do you identify as
Male
Female
Do you have sex with
Male
Female
Currently, how many sexual partner(s) do you have?
One
More than one
None/abstinent
What types of sex do you have?
Anal
Vaginal
Oral
Have you are your partner had sexually transmitted infection(s) (STI/STD)? Check all that apply
NONE
Syphilis
Gonorrhea
Chlamydia
HPV
HIV
Hepatitis B/C
Would you like to get tested for STI/STD?
Yes
No
Do you have other concerns that you would like to discuss with Dr. Schechter about your sexual health? Notes here:
* Required field
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