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Get WA DOH 347-102 - Thurston County 2013

Rt STDs within three work days (WAC 246-101-101/301) PATIENT INFORMATION LAST NAME FIRST NAME ADDRESS CITY DATE OF BIRTH MO SEX YR ( ETHNICITY Male Female Transgendered Male to Female Transgendered Female to Male If Female, PREGNANT? ) RACE (Check all that apply) DAY Male Female Both Unknown HIV TESTED AT THIS VISIT?* Symptomatic Routine Exam – No Symptoms Exposed to Infection Unknown GENDER OF SEX PARTNERS White Asian Black Other Unknown American Indian/Alaskan Native Native Ha.

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