Sexual Health Care Plans


Key Objectives

Provide patients with information about their procedure and collect information from the patient before their appointment to reduce clinic time and to support patient empowerment.


Outcome measures

Equip patients with the information they need before their appointment, also providing the tools they need to interact digitally rather than relying on face to face consultations.


Current Baselines

The patient arrives at the clinic. Information is explained to the patient and the nurse goes through a questionnaire/checklist with the patient, appointments aren’t being efficient and patients are having long waiting times.


Workflow

Coil fitting checklist care plan

Example care plan template code for Coil fitting checklist Care Plan HTML

<div class="form-inline">

<style media="screen">

.form-group {width: 100%; !important}

ul {list-style:inherit; margin-left: 15px;}

.cp_whiteBox_orange {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px; border: 2px solid #FEC001;}

.cp_whiteBox_red {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px; border: 2px solid red;}

.cp_colorBox {background-color: #ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px;}


</style>


<div class="cp_colorBox">

<h2>Coil fitting checklist - for intrauterine devices (IUD) and intrauterine systems (IUS)</h2>

<p>Please complete this checklist to ensure that we are able to fit your coil at your booked

appointment. This checklist will also provide you with some important information about

having a coil fitted.</p>

</div>


<div class="cp_colorBox">

<p>Please watch the video below or read <a href="https://www.contraceptionchoices.org" target="_blank">the contraception

Choices website</a> before completing this form.</p>

<div class="embed-responsive embed-responsive-16by9">

<iframe class="embed-responsive-item" src="https://www.youtube.com/embed/bn9BTOrABa4" allowfullscreen="true"></iframe>

</div>

</div>


<div class="cp_colorBox">

<p>Please tick the boxes to confirm that you have understood and are ready to book your coil fitting appointment:</p>


<div class="cp_colorBox" style="background-color: #f7d5e0;">

<p>I have watched the video above on coils or I have read the <a href="https://www.contraceptionchoices.org" target="_blank">contraception

Choices website</a> or I already have an IUD/IUS and am familiar with this contraception method</p>

<input type="radio" id="cp_q1yes" name="cp_q1" value="yes" aria-label="Yes">Yes</input>

<input type="radio" id="cp_q1no" name="cp_q1" value="no" aria-label="No">No</input>

</div>


<div class="cp_colorBox" style="background-color: #f7d5e0;">

<p>I am using an effective method of contraception and haven't had any problems eg burst condom, missed pills, IUD overdue for change.</p>

<input type="radio" id="cp_q2yes" name="cp_q2" value="yes" aria-label="Yes">Yes</input>

<input type="radio" id="cp_q2no" name="cp_q2" value="no" aria-label="No">No</input>

</div>


<div class="cp_colorBox" style="background-color: #f7d5e0;">

<p>I have not had unprotected sex (or used the withdrawal method) since my last period.</p>

<input type="radio" id="cp_q3yes" name="cp_q3" value="yes" aria-label="Yes">Yes</input>

<input type="radio" id="cp_q3no" name="cp_q3" value="no" aria-label="No">No</input>

</div>


<div class="cp_colorBox" style="background-color: #f7d5e0;">

<p>I understand that it is not safe to insert an IUD/IUS if I might be pregnant.</p>

<input type="radio" id="cp_q4yes" name="cp_q4" value="yes" aria-label="Yes">Yes</input>

<input type="radio" id="cp_q4no" name="cp_q4" value="no" aria-label="No">No</input>

</div>


<div class="cp_colorBox" style="background-color: #f7d5e0;">

<p>I will make sure that I have eaten on the day of the appointment. (You may also wish to take an over-the-counter

painkiller 30 minutes before your appointment.)</p>

<input type="radio" id="cp_q5yes" name="cp_q5" value="yes" aria-label="Yes">Yes</input>

<input type="radio" id="cp_q5no" name="cp_q5" value="no" aria-label="No">No</input>

</div>


<div class="cp_colorBox" style="background-color: #f7d5e0;">

<p>I understand that an IUD/IUS is more than 99 per cent effective (less than 1 in 100 chance of pregnancy).</p>

<input type="radio" id="cp_q6yes" name="cp_q6" value="yes" aria-label="Yes">Yes</input>

<input type="radio" id="cp_q6no" name="cp_q6" value="no" aria-label="No">No</input>

</div>



<div class="cp_colorBox" style="background-color: #f7d5e0;">

<p>I understand that there is a small risk (1 in 1,000) that the IUD/IUS might go through (perforate)

my womb or cervix when it is put in. If this does happen, the IUD/IUS may have to be removed surgically.</p>

<input type="radio" id="cp_q7yes" name="cp_q7" value="yes" aria-label="Yes">Yes</input>

<input type="radio" id="cp_q7no" name="cp_q7" value="no" aria-label="No">No</input>

</div>


<div class="cp_colorBox" style="background-color: #f7d5e0;">

<p>I understand that there is a 1 in 20 chance of the device falling out.</p>

<input type="radio" id="cp_q8yes" name="cp_q8" value="yes" aria-label="Yes">Yes</input>

<input type="radio" id="cp_q8no" name="cp_q8" value="no" aria-label="No">No</input>

</div>


<div class="cp_colorBox" style="background-color: #f7d5e0;">

<p>I understand that there is a small risk of infection (1 in 100) in the first 20 days following insertion of a device.</p>

<input type="radio" id="cp_q9yes" name="cp_q9" value="yes" aria-label="Yes">Yes</input>

<input type="radio" id="cp_q9no" name="cp_q9" value="no" aria-label="No">No</input>

</div>


<div class="cp_colorBox" style="background-color: #f7d5e0;">

<p>I know that a copper IUD will make my periods slightly heavier, longer and more painful.</p>

<input type="radio" id="cp_q10yes" name="cp_q10" value="yes" aria-label="Yes">Yes</input>

<input type="radio" id="cp_q10no" name="cp_q10" value="no" aria-label="No">No</input>

</div>


<div class="cp_colorBox" style="background-color: #f7d5e0;">

<p>I know that an IUS will make my periods much lighter but causes erratic bleeding and spotting in the first few months of use.</p>

<input type="radio" id="cp_q11yes" name="cp_q11" value="yes" aria-label="Yes">Yes</input>

<input type="radio" id="cp_q11no" name="cp_q11" value="no" aria-label="No">No</input>

</div>


<div class="cp_colorBox" style="background-color: #f7d5e0;">

<p>I do not believe I am at risk of sexually transmitted infections (STIs) or I have been tested negative recently for

Chlamydia / Gonorrhoea. Risk factors for STI are having a new partner in the last 3 months or more than one partner

in the last year - we recommend you have a negative test before the procedure. Order yours at

<a href="https://www.friskywales.org" target="_blank">Frisky Wales</a></p>

<input type="radio" id="cp_q12yes" name="cp_q12" value="yes" aria-label="Yes">Yes</input>

<input type="radio" id="cp_q12no" name="cp_q12" value="no" aria-label="No">No</input>

</div>


</div>


</div>


Sub-dermal implant insertion checklist care plan


Key Objectives

Provide patients with information about their procedure and collect information from the patient before their appointment to reduce clinic time and to support patient empowerment.


Outcome measures

Equip patients with the information they need before their appointment, also providing the tools they need to interact digitally rather than relying on face to face consultations.


Current Baselines

The patient arrives at the clinic. Information is explained to the patient and the nurse goes through a questionnaire/checklist with the patient, appointments aren’t being efficient and patients are having long waiting times.

Example care plan template code for Sub-dermal implant insertion Care Plan HTML


Contraceptive Pill Checklist care plan

Key Objectives

Provide patients with information about their procedure and collect information from the patient before their appointment to reduce clinic time and to support patient empowerment.


Outcome measures

Equip patients with the information they need before their appointment, also providing the tools they need to interact digitally rather than relying on face to face consultations.


Current Baselines

The patient arrives at the clinic. Information is explained to the patient and the nurse goes through a questionnaire/checklist with the patient, appointments aren’t being efficient and patients are having long waiting times.


Workflow

  1. Admin: calls patient offering appointment and PKB

  2. Admin: creates an appointment and adds care plan into PKB

  3. PKB: notifies patient about appointment and care plan are in their record

  4. Patient: fills in informed questionnaire care plan before the appointment

  5. Patient: attends appointment for contraceptive pill advice and prescription

  6. Professional: reviews answers in the care plan

  7. Professional: prescribes the contraceptive pill

  8. Professional: team-based messaging available to the patient for follow up instructions and questions

Evaluation

  • Reducing phone calls and contacts

  • Patient reduce coming back in for more contraception

  • The ability for patients to contact the team if they have any issues after starting the contraceptive pill

  • Women able to track symptoms in relation to the contraceptive pill

  • Record weight

  • Record BP when they get it checked at the GP

  • Library of different contraception options

Example care plan template code for Contraceptive Pill Checklist Care Plan HTML

<div class="form-inline">

<style media="screen">

a {word-wrap: break-word;}

.form-group {width: 100%; !important}

.cp_label {font-size: 18px;font-weight: 900;}

.cp_whiteBox {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; -moz-border-radius: 10px; -webkit-border-radius: 10px; -khtml-border-radius: 10px; border-radius: 10px;}

</style>


<div class="cp_whiteBox">

<p>Please complete these questions before your appointment.</p>

<p>To complete this form, please click the 'Edit plan' button in the top right of the page.</p>

<p>When you have answered all the questions, please click 'Save' in the bottom right of the page.</p>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q1">1. Are you currently using any kind of hormonal contraception?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q1" id="cp_q1Yes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q1" id="cp_q1No" value="No"> No</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If yes:</h3><br></br>

<label class="cp_label" for="cp_q1a">What is your current contraceptive? </label><input type="text" name="cp_q1a" id="cp_q1a"></input>

<label class="cp_label" for="cp_q1b">Would you like to change to another contraceptive? Please say why:</label><textarea name="cp_q1b" id="cp_q1b" style="width: 90%" rows="3"></textarea>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If no:</h3>

<label class="cp_label" style="margin-top: 20px;" for="cp_q1b">Have you used hormonal contraceptives in the past? Please specify any you have used: </label><input type="text" name="cp_q1bYesText" id="cp_q1bYesText"></input>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q2">2. Do you know the pill you would like to order?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q2" id="cp_q2Combined" value="Combined"> Combined pill</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q2" id="cp_q2POP" value="POP"> Progestogen only pill</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q2" id="cp_q2unknown" value="unknown"> Don't know</input>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q3">3. Have you had your blood pressure measured in the last 12 months?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q3" id="cp_q3Yes" value="Yes"> Yes (if known, please enter reading and date at the top of this form)</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q3" id="cp_q3No" value="No"> No</input>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q4">4. Are you allergic to any medications or substances?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q4" id="cp_q4Yes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q4" id="cp_q4No" value="No"> No</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If yes, please specify below:</h3>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q4a" id="cp_q4a" value="penicillin"> Penicillin</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q4b" id="cp_q4b" value="peanutSoya"> Peanuts or soya</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q4c" id="cp_q4c" value="lactose"> Lactose</input>

</div>

<label class="cp_label" for="cp_q4aotherMeds"> Other medications: </label><input type="text" name="cp_q4aotherMeds" id="cp_q4aotherMeds"></input>

<label class="cp_label" for="cp_q4aotherSubs"> Other substances: </label><input type="text" name="cp_q4aotherSubs" id="cp_q4aotherSubs"></input>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q5">5. Do you smoke?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q5" id="cp_q5Yes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q5" id="cp_q5No" value="No"> No</input>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;">6. Are you pregnant or have you given birth in the last 6 weeks?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q6" id="cp_q6a" value="pregnant"> I am pregnant or there is a chance I could be</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q6" id="cp_q6b" value="less than 3 weeks"> I gave birth in the last 3 weeks</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q6" id="cp_q6c" value="3-6weeks"> I gave birth in the last 3-6 weeks</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q6" id="cp_q6d" value="NoneOfAbove"> None of the above</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If you have given birth in the last 3-6 weeks:</h3>

<label class="cp_label" style="margin-top: 20px;" for="cp_q7a">Are you breastfeeding?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q7a" id="cp_q7aYes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q7a" id="cp_q7aNo" value="No"> No</input>

</div>


<label class="cp_label" style="margin-top: 20px;">Did you have:</label>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q7b" id="cp_q7b" value="transfusion"> Blood transfusion or significant blood loss</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q7c" id="cp_q7c" value="Csection"> Caesarian section</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q7d" id="cp_q7d" value="preeclampsia"> Pre-eclampsia during or after pregnancy</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q7e" id="cp_q7e" value="None"> None of the above</input>

</div>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q8">7. Have you been diagnosed with high blood pressure?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q8a" id="cp_q8aYes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q8a" id="cp_q8aNo" value="No"> No</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If yes:</h3><br></br>

<label class="cp_label" style="margin-top: 20px;">Was it related to:</label>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q8b" id="cp_q8b" value="pregnancy"> Pregnancy</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q8c" id="cp_q8c" value="whitecoat"> White coat syndrome</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q8d" id="cp_q8d" value="other"> Other</input>

</div>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q9a">8. Have you ever had a heart attack or stroke?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q9a" id="cp_q9aYes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q9a" id="cp_q9aNo" value="No"> No</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If yes:</h3>

<label class="cp_label" for="cp_q9b">Please give details of what happened, when, and the treatment you had: </label><textarea name="cp_q9b" id="cp_q9b" style="width: 90%" rows="3"></textarea>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q10">9. Have you had a blood clot before?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q10a" id="cp_q10aYes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q10a" id="cp_q10aNo" value="No"> No</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If yes:</h3><br></br>

<label class="cp_label" for="cp_q10b">Please provide details: </label><textarea name="cp_q10b" id="cp_q10b" style="width: 90%" rows="3"></textarea>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q11">10. Has someone in your close family had a blood clot?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q11a" id="cp_q11aYes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q11a" id="cp_q11aNo" value="No"> No</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If yes:</h3><br></br>

<label class="cp_label" for="cp_q11b">What relation were they to you? </label><input type="text" name="cp_q11b" id="cp_q11b"></input>

<label class="cp_label" style="margin-top: 20px;" for="cp_q11c">How old were they?:</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q11c" id="cp_q11cGT44" value="greater than 44"> 45 years old or over</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q11c" id="cp_q11cLT45" value="less than 45"> Less than 45 years old</input>

</div>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q12">11. Have you had major surgery in the last 3 weeks?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q12a" id="cp_q12aYes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q12a" id="cp_q12aNo" value="No"> No</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If yes:</h3><br></br>

<label class="cp_label" for="cp_q12b">Please provide details: </label><textarea name="cp_q12b" id="cp_q12b" style="width: 90%" rows="3"></textarea>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q13">12. Do you have diabetes?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q13a" id="cp_q13aYes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q13a" id="cp_q13aNo" value="No"> No</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If yes:</h3><br></br>

<label class="cp_label" for="cp_q13b">Please provide details: </label><textarea name="cp_q13b" id="cp_q13b" style="width: 90%" rows="3"></textarea>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q14">13. Do you have any conditions affecting your liver or kidneys?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q14a" id="cp_q14aYes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q14a" id="cp_q14aNo" value="No"> No</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If yes:</h3><br></br>

<label class="cp_label" for="cp_q14b">Please provide details: </label><textarea name="cp_q14b" id="cp_q14b" style="width: 90%" rows="3"></textarea>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;">14. Have you ever had any of the following cancers? (select all that apply)</label>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q15b" id="cp_q15b" value="Breast cancer"> Breast cancer</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q15c" id="cp_q15c" value="Cervical cancer"> Cervical cancer</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q15d" id="cp_q15d" value="Liver cancer"> Liver cancer</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q15e" id="cp_q15e" value="Other cancers"> Other cancers</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q15f" id="cp_q15f" value="Never had cancers"> Never had cancers</input>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q16">15. Do you ever have unexpected or unusual vaginal bleeding?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q16a" id="cp_q16aYes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q16a" id="cp_q16aNo" value="No"> No</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If yes:</h3><br></br>

<label class="cp_label" for="cp_q16b">How long have you had it? When did it happen last? </label><textarea name="cp_q16b" id="cp_q16b" style="width: 90%" rows="3"></textarea>

<label class="cp_label" style="margin-top: 20px;">Select all that apply:</label>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q16c" id="cp_q16c" value="PCB"> Bleeding during or after sexual intercourse</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q16d" id="cp_q16d" value="Heavy bleeding"> Heavy bleeding</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q16e" id="cp_q16e" value="Very painful bleeding"> Very painful bleeding</input>

</div>

<div class="form-check">

<input class="form-check-input form-control" type="checkbox" name="cp_q16f" id="cp_q16f" value="None of above"> None of the above</input>

</div>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q17">16. Have you had a STI test in the last 12 months or since your last new sexual partner?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q17a" id="cp_q17aYes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q17a" id="cp_q17aNo" value="No"> No</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If yes:</h3><br></br>

<label class="cp_label" for="cp_q17b">What were the results? </label><input type="text" name="cp_q17b" id="cp_q17b"></input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If no:</h3>

<p>Please consider ordering a full STI screen through <a href="www.friskywales.org" target="_blank" rel="noopener noreferrer">www.friskywales.org</a></p>

</div>

</div>


<div class="cp_whiteBox">

<h3>17. If you are 25 years or older:</h3>

<label class="cp_label" for="cp_q18a">When was your last cervical smear? </label><input type="text" name="cp_q18a" id="cp_q18a"></input>

<label class="cp_label" for="cp_q18b">What was the smear result? </label><input type="text" name="cp_q18b" id="cp_q18b"></input>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q20">18. Do you have any other medical conditions?</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q20a" id="cp_q20aYes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q20a" id="cp_q20aNo" value="No"> No</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If yes:</h3><br></br>

<label class="cp_label" for="cp_q20b">Please provide details: </label><input type="text" name="cp_q20b" id="cp_q20b"></input>

</div>

</div>


<div class="cp_whiteBox">

<label class="cp_label" style="margin-top: 20px;" for="cp_q21">19. Are you taking any medications currently or have recently finished a course of medication? (including over the counter medications)</label>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q21a" id="cp_q21aYes" value="Yes"> Yes</input>

</div>

<div class="form-check">

<input class="form-check-input" type="radio" name="cp_q21a" id="cp_q21aNo" value="No"> No</input>

</div>


<div style="margin-left:50px; background-color: #CCDDE2; padding: 7px;">

<h3>If yes:</h3>

<label class="cp_label" for="cp_q21b">Please provide medication name, dose and what it was used for: </label><textarea name="cp_q21b" id="cp_q21b" style="width: 90%" rows="3"></textarea>

</div>

</div>





</div>