Explain your symptoms or tell us how we can help today.*

Do you have allergies to any medications?*

Yes
No

If yes, please list any medications you have allergies to:

Are you pregnant or breastfeeding?*

Yes
No

Unfortunately we cannot proceed with your request based on the information you have provided.

Describe your recent sexual behavior:*

New sex partner
Unprotected sex
Multiple sex partners
Sex partner with sexually transmitted infection (STI)
None of the above

What area is affected?*

Penis
Scrotum
Vagina
Mouth/throat
Rectal

What symptoms have you been experiencing recently?*

Unfortunately we cannot proceed with your request based on the information you have provided.

Please describe the rashes:*

Palms of hands
Soles of feet
Other

If you said other, please describe the rash:*

Unfortunately we cannot proceed with your request based on the information you have provided.

Please best explain the description of fever or chills:*

Feeling warm no measured temperature
Measured temperature of 100.8 degrees (fahrenheit) or higher
Severe uncontrollable chills (teeth chattering)

Unfortunately we cannot proceed with your request based on the information you have provided.

How Long have you been having these symptoms?*

Started today
1-3 days
4-7 days
Over 1 week

Have you ever been treated for syphilis?*

Yes
No

How long ago?*

What medications were you treated with?*

Penicillin
Doxycycline
Other

Please list the treatment plan:*

Did treatment work?*

Yes
No

Would you prefer the same treatment?*

Yes
No
Leave to doctor’s discretion

Smoker?*

Yes
No
Never

Alcohol use?*

Any medical family history?*

Yes
No

Please explain your medical family history:*

Do you have any medical conditions?*

Yes
No

Please explain your medical conditions:*

Have you ever had any surgeries or recent hospitalizations?*

Yes
No

Please explain your surgeries or recent hospitalizations:*

Do you currently take any medications, herbals, or supplements?*

Yes
No

Please list any medications, herbals, or supplements:*

Do you have a urinary catheter or foley catheter?*

Yes
No

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