Sti Medication Administration Reporting Form

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STI MEDICATION ADMINISTRATION REPORTING FORM
All publicly-funded STI medication administered to clients MUST be reported to Manitoba Health, Healthy Living and Seniors. Complete this form and
th
Floor – 300 Carlton Street Winnipeg, MB R3B 3M9
send it monthly to Communicable Disease Control by Fax: (204) 948-2040 OR Mail: 4
Name of Clinic: _____________________________________________Name of Doctor: ________________________________________
Date: _______________________________________
Treatment Recommendations: For more information, please refer to the Sexually Transmitted and Blood-Borne Infections page on the
Communicable Disease Control website
Treatment Provided (Indicate number(s)
PHIN (If no PHIN, give MHSC
Date of Treatment
Diagnosis (Indicate number
from list below. More than one treatment
number and date of birth)
(yyyy/mm/dd)
from list below)
can be listed)
List of Diagnoses
List of Treatments (Publicly-funded)
01 = Suspected case or contact to gonorrhea or chlamydia
02 = Azithromycin 1.0 gm single dose
12 = Amoxicillin 500 mg po, TID for 7 days
03 = Lab-confirmed chlamydia
03 = Azithromycin 1.0 gm once weekly for three
13= Bicillin (Benzathine penicillinG) 2.4 MU IM
weeks
single dose
05 = Lab-confirmed gonorrhea
04 = Ceftriaxone 250 mg IM, single dose
14 = Bicillin (Benzathine penicillinG) 2.4 MU IM
once weekly for three weeks
07 = Lab-confirmed Syphilis
06 = Ciprofloxacin 500 mg single dose
15 = Metronidazole 500 mg BID For 14 days
08 = Suspected case or contact to Syphilis
07 = Doxycycline 100 mg BID for 7 days
18 = Azithromycin 2.0 gm single dose
09 = Pelvic inflammatory disease (PID)
08 = Doxycycline 100 mg BID for 14 days
19 = Doxycycline 100 mg BID for 28 days
10 = Lymphogranuloma Venereum (LGV)
09 = Doxycycline 100 mg BID for 21 days
20 = Cefixime 800 mg single dose
11 = Chancroid
10 = Erythromycin base 500 mg QID for 7 days
17 = Other (Please specify):
12 = Other (Please specify):
11 = Erythromycin base 500 mg QID for 21 days
June 2015

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