Voucher: FBOH

Invoiced

YesNo

Patient County *

Sweetwater County

Age Range

10-1415-1920-2425-3435-5051-6465+

Transgender

YesNo

Sex at birth

MaleFemale

Patient Gender Identity

• Female
• Male
• Genderqueer
• Non-binary
• Two-spirit

Insurance Status

InsuredUninsured

Sexually active, no other risks

YesNo

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

AlwaysMore than half the timeHalf the timeLess than half the timeNever

How did the patient hear about KnoWyo?

Clinic referralCondom dispenserDating app adEventOtherPosterRadio or music adReferral by CDU staffSocial MediaTV/Streaming adWebsite ad

Test(s)

• Hepatitis B panel (hepatitis B surface antibody, surface antigen, core IgM)
• HIV antibody/antigen blood draw, NO RAPID DONE OR CONTROLS FAILED
• HIV CONFIRMATORY blood draw for REACTIVE RAPID TEST ONLY, must notify CDU Area DIS
• Urine specimen – Chlamydia and Gonorrhea

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