Why do we need this questionnaire?

Help us help the Arkansas Department of Health in fighting sexually transmitted disease.

 

Take only a few minutes to check the boxes on the following questions about sexual health history.

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Your information is strictly confidential. This form will be shared with no one but your healthcare provider. Your honest answers will help your doctor to help you optimize your health. If a question does not apply to you, check the N/A (Not Applicable) box or leave it blank.