University Health Services

The information you provide is PRIVATE and CONFIDENTIAL. It is used for the provision of a sexual health screening and ongoing management by the University Health Service. The information we collect that relates to sex, sexuality and gender diversity is to ensure we provide appropriate care to all of our UNSW community. Remember the information we collect will not be shared without your permission, it remains PRIVATE and CONFIDENTIAL.

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* 1. Full Name (as per your health care card):

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* 2. Address:

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* 3. Suburb and postcode:

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* 4. Email:

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* 5. Mobile:

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* 6. Date of Birth (DD/MM/YYYY):

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* 7. Country of Birth:

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* 8. Language spoken at home:

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* 9. Medicare Number (Domestic students)

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* 10. Overseas Health Care Provider (International students)

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* 11. Overseas Health Care policy number (International students)

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* 12. Are you a current patient at the UNSW Health Service?

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* 13. Are you a:

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* 14. Are you of Aboriginal or Torres Strait Island origin?

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* 15. Student/staff zID:

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* 16. Sex recorded at birth (i.e. the sex on your original birth certificate):

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* 17. How do you describe your gender?

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* 18. Were you born with a variation of sex characteristics (sometimes called 'intersex' or 'Disorders of Sex Development' (DSD)?

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* 19. How do you describe your sexuality? 

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* 20. Have you had sex before?

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* 21. Have you ever had a sexual health screen before?

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* 22. Have you been vaccinated for HPV?

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* 23. Have you been vaccinated for Hepatitis B? 

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* 24. Have you had a meningococcal vaccination before?

Thank you for filling in your details. Please press the 'Done' button below to complete the registration process.

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