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Voucher: 4KUG
Invoiced
Yes
No
Patient County
*
Age Range
10-14
15-19
20-24
25-34
35-50
51-64
65+
Transgender
Yes
No
Sex at birth
Male
Female
Patient Gender Identity
Female
Male
Genderqueer
Non-binary
Two-spirit
Insurance Status
Insured
Uninsured
Sexually active, no other risks
Yes
No
Risk Factor(s)
Contact to positive
Symptoms
New partner
Test of cure
Prior positive follow-up
Injection drug use
Non-injection drug use
Anonymous partner
Partner from app or internet
Pregnant
Unprofessional/Homemade tattoos or piercings
Multiple partners
Partner has other partners
Current homelessness
Past history of homelessness
Current resident of a detention facility
Past resident of a detention facility
Survivor of sexual assault/abuse
Consistently abnormal liver tests
Condom Use
Always
More than half the time
Half the time
Less than half the time
Never
How did the patient hear about KnoWyo?
Clinic referral
Condom dispenser
Dating app ad
Event
Other
Poster
Radio or music ad
Referral by CDU staff
Social Media
TV/Streaming ad
Website ad
Test(s)
Vaginal specimen – Chlamydia and Gonorrhea
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