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Cardiff Integrated Sexual Health Clinic

Walk-in assessment form for confidential STI screening and sexual health support.

Clinic Code: CIS-FP-02 Location: Family Planning

Patient details

Full name*

As appears on your ID.

Date of birth*

Gender identity

Pronouns

Mobile number*

Reason for visit today

Main reason*

Routine sexual health check I have symptoms Told I may have been exposed Other

Choose the option that best describes why you are here today.

Please describe any symptoms

Recent sexual health history

Sexual partners in the last 3 months

Gender(s) of partner(s)

Did you use condoms or barriers?

Always Sometimes Never

Is there anything specific you are worried about?

Consent and results

GLITCH EFFECT

TORI VOICE