Transcription of SEXUALLY TRANSMITTED DISEASE - CONFIDENTIAL …
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SEXUALLY TRANSMITTED DISEASE - CONFIDENTIAL …
SEXUALLY TRANSMITTED DISEASE - CONFIDENTIAL MORBIDITY REPORTPATIENT'S LAST NAMEPATIENT'S STREET code --Date of Report:FIRST NAMEAPT/UNIT Chlamydia (including LGV) GonorrheaSyphilis (for syphilis fill out back of form & fax both sides) DISEASE (s) Being Report ed: C hancroid HOME Done by:Patient Pregnant? Unk. No YesLMP: ----CELLE-MAIL ADDRESSP artner Pregnant? Unk. No Yes Specimen collection date:--Gender: MaleFemaleTransgender MtoFTransgender FtoMUnknownOtherGonorrhea:UrineCervixVag inaUrethraRectumPharyngealOther:_____Sit e/specimen(s) with positive result: Chlamydia/Gonorrhea DiagnosisAsymptomaticSymptomatic - uncomplicated Eye infection Disseminated gonorrhea Lymphogranuloma venereum (LGV) Other:_____Medication(s) and Doses: Not treatedCeftriaxone 250mg IM Azithromycin 1g po Azithromycin 2g po Doxycycline 100mg bid x 7d Doxycycline 200mg q day x 7d Cefixime 400mg poGentamicin 240 mg IM Other med(s):_____Partner Info.
SEXUALLY TRANSMITTED DISEASE - CONFIDENTIAL MORBIDITY REPORT PATIENT'S LAST NAME PATIENT'S STREET ADDRESS M.I. BIRTHDATE CITY/TOWN STATE ZIP CODE Date of - - Report: FIRST NAME APT/UNIT NO.-Disease(s) Being Chlamydia (including LGV) Gonorrhea Syphilis (for syphilis fill out back of form & fax both sides) Report ed: Chancroid …
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