info@huisartsenpraktijkdevecht.nl

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Questionnaire

Would you answer the questions below to the best of your ability? The completed questionnaire will be discussed with you during the consultation hour. The completed questionnaire will be treated confidentially.

Form STD

Name
This field is for validation purposes and should be left unchanged.
Personal data
Name*
Gender
- Man
- Woman
Date of birth
DD slash MM slash YYYY
Phone number
Email address*
Nationality
Country of birth
Questionnaire
What is the reason you are coming for an STI test?
Have you had an STI before?
- Yes
- No
Has your sex partner ever had an STI?
- Yes
- No
- Unknown
Have you had unsafe sexual contact in the past six months?
Has your sex partner(s) had unsafe sexual contact in the past six months?
In what way did you have (unsafe) sexual contact?
What is the date of the last unsafe sexual contact?
DD slash MM slash YYYY
How many sex partners have you had in the past six months?
In the past six months, have you had sexual contact with:
Can there be pregnancy (for women only)?
- Yes
- No
- Unknown
Have you had sexual contact for payment?
- Yes
- No
Have you taken drugs by injection?
- Yes
- No
Have you been vaccinated against hepatitis B?
- Yes
- No
Do you need information on safe sex?
- Yes
- No
Are there any other things we need to know or do you have any questions?

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Address

Vechtstraat 80
9725CW Groningen

Telephone numbers

Phone:
Express line:
Recipe line:

050-525 94 99
050-526 26 00
050-527 97 17

Email address

info@huisartsenpraktijkdevecht.nl

Should I go to the GP?

GPs
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STD Consultation
LIV Self-care
Blood collection
Travel advice
Sports Medicine
Skin consultation
Dietician

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Vechtstraat 80
9725 CW Groningen

Contact information

Phone: 050-525 94 99
Express line: 050-526 26 00
Recipe line: 050-527 97 17
E-mail: info@huisartsenpraktijkdevecht.nl

Emergency outside opening hours?

Do you require urgent assistance outside of our opening hours? Please contact
DockNorth Huisartsenspoedpost, 088-330 1 330.

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