|
Accompanied by
|
Unaccompanied
|
|
Reason for visit
• • •
|
Comments
|
|
LMP
|
Comments
|
|
Birth control
|
Comments
|
|
Sexual activity
• • •
|
Comments
|
|
Condom use
|
Comments
|
|
No. of partners
|
Sex of partners
|
|
Symptoms (-)
• • •
|
Comments
|
|
Symptoms (+)
• • •
|
Comments
|
|
History (+)
• • •
|
Comments
|
|
|
|
|
History (-)
• • •
|
|
|
Exam normal
|
|
|
|
|
|
Plan
• • •
|
|
