Please fill your details on to the paper form the receptionist gave to you. Each numbered question below has a numbered box on the form.
- Have you used our services before? Put a tick for yes ✔️ or a cross for no❌
2. Title (e.g. Miss / Mr / Mrs / Mx / Dr )
3. First name
4. Surname
5. Preferred name
6. Previous name
7. Date of birth
8. Age
9. Gender at birth (choose male ♂️ or female♀️)
10. Gender identity (choose male, female, non-binary or other)
11. Country of birth
12. Nationality
13. GP Surgery (Name of doctors practice)
14. Home address
15. Postcode
16. Mobile phone number
17. Email address
18. Do you have a PHR account? Put a tick for yes ✔️ or a cross for no❌
19. Results are usually sent out by text message. Please tick ✔️ all other ways you are happy for us to contact you, next to the icon.
(phone call / text message / voicemail / letter)
20. What is your ethnic origin? (see options below)
- OPTION 1 – Asian or Asian British – Bangladeshi
- OPTION 2 – Asian or Asian British – Indian
- OPTION 3 – Asian or Asian British – Pakistani
- OPTION 4 – Asian or Asian British – Other
- OPTION 5 – Black or Black British – African
- OPTION 6 – Black or Black British – Caribbean
- OPTION 7 – Black or Black British – Other
- OPTION 8 – Mixed – Other
- OPTION 9 – Mixed – White and Asian
- OPTION 10 – Mixed – White and Black African
- OPTION 11 – Mixed – White and Black Caribbean
- OPTION 12 – Not stated
- OPTION 13 – Other ethnic groups – Chinese
- OPTION 14 – Other ethnic groups – Other
- OPTION 15 – White – British
- OPTION 16 – White – Irish
- OPTION 17 – White – Other
21. Do you require an interpreter? Put a tick for yes ✔️ or a cross for no❌
22. If you do need an interpreter, which language do you require?
23. Do you have any other specific communication requirements? Put a tick for yes ✔️ or a cross for no❌
24. If yes, please let us know how we can assist you
25. Why are you here today? (see below)
- OPTION 1 – I have symptoms/genital problems or an infection
- OPTION 2 – I have NO symptoms/genital problems but would like a sexual health screen
- OPTION 3 – I am a contact of infection
- OPTION 4 – I would like condoms and/or lube
- OPTION 5 – I would like emergency contraception
- OPTION 6 – I would like contraception
- OPTION 7 – Other reason
Thank you. Please return your paper form back to reception.
Some of our services are available online via our website, as well as information about contraception, STIs and more.
www.leicestersexualhealth.nhs.uk
To find out more about how your data is stored and confidentiality, please visit the link below:
www.mpft.nhs.uk/about-us/privacy-notice