Wyoming Department Of Health - Communicable Disease Hiv, Hepatitis And Std Risk Assessment Page 4
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4Wyoming Department of Health – Communicable Disease HIV, Hepatitis and STD Risk Assessment
Positive Test Results
Post-Test Education
Action
Comments
Risk reduction plan reviewed
Need for follow up testing
Follow up appointment if needed
Updates on referrals
Immunizations, Dates initiated:
Hep A:___________ Hep B:______________ Twinrix:____________ HPV:______________
HIV Services Program if positive
Partner services
All positive/reactive tests must be reported to the Wyoming Department of Health Communicable Disease Unit. Please report online
through the Electronic Confidential Disease Report (ECDR) at https://prismdata.health.wyo.gov/ or through the Patient Reporting
Investigation Surveillance Manager (PRISM). Date Reported: ______________
Client received results: Date _____________________
In person
By Phone
Certified Letter
Unable to locate patient, provide justification: ___________________________________________________________________
Treatment
Client treated for:
Chlamydia
Gonorrhea
Syphilis
Not treated, provide justification: ____________________________
Medication provided: Date: _______________________ Time:_________________ (am / pm)
Referral made for:
HIV
Hepatitis B
Hepatitis C.
Date: _______________
Chlamydia
Azithromycin 1gm
Doxycycline 100mg bid x 7d
Other: ________________________________________________
Gonorrhea
Ceftriaxone 250mg IM
Azithromycin 1gm PO
PLUS
OR
Doxycycline 100mg qd x 7d
Syphilis
Primary,Secondary, and Early Latent: Benzathine penicillin G 2.4mu IM
Latent > 1 year: Benzathine penicillin G 2.4mu IM x 3 doses at weekly intervals
Dose 1 date:
Dose 2 date:
Dose 3 date:
Notes: ______________________________________________________________________________________________________
____________________________________________________________________________________________________________
Provider prescribing treatment: ___________________________________________
____________________________________
(Print name and credentials)
(Signature)
Medication instructions provided
Disease information sheet provided
Partner Services
*The Wyoming Department of Health Communicable Disease Unit Clinic Interview may be used as a reference for Partner Services*
Name: ________________________________________________________________ DOB: _______________________________
Address: ___________________________________________________________________________________________________
Email: __________________________________________________________ Phone number: _______________________________
Partner Treated:
Yes, date and treatment provided: ______________________________________________________________
No, provide justification: ______________________________________________________________________
EPT Provided:
Yes, date and treatment provided: ______________________________________________________________
No, provide justification: ______________________________________________________________________
Staff Signature: __________________________________________________________ Date: ____________________________
Client Initials: _________________
June 23, 2016
Page 4
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