CLINIC LABEL
MALE
SELF-ASSESSMENT FORM FOR CHECK AND GO
NAME ………………………………………………
MY MOBILE NUMBER IS: …………………………………
If you have no symptoms and you just need a check up for peace of
mind
.





Fill out and sign an assessment form and see a nurse.
You choose which tests you want
A swab test for gonorrhoea and Chlamydia
,
Blood tests for HIV and Syphilis
Results will be by text message –in 2-3 weeks
Free condoms,
 No treatment
Tell the receptionist if you feel that this service is not what you require.
When did you last pass urine
less than 2 hours
Have you ever had sex with a man?
yes
on
Have you ever injected drugs?
Request for tests:
I would like to have the following tests:
yes
on
Swab/urine test for Gonorrhoea
yes
on
Swab/urine test for Chlamydia
yes
on
Blood test for HIV
yes
on
Blood test for Syphilis
yes
on
Consent
I confirm that I have read and understood the information form about Gonorrhoea,
Chlamydia, HIV and Syphilis testing. I understand that I will not be tested for other
condition, have any discussion regarding lifestyle changes or be provided with any
contraception other than condoms. I request that the result should be sent by text
message.
Signature:………………………………………….. Date: ………….
To be completed by health care workers
Number of 3months 1 year Test
partners
Male
Female
Taken Date
Sign
G.C
Chlamydia
sts
HIV
KC60 CODES
Nurse signature……………………………………... Date…………..