Form 2808 - Sexually Transmitted Diseases 2014
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1
2Sexually Transmitted Diseases
N.C. Department of Health and Human Services
Division of Public Health
Form 2808
1. Last Name
First Name
Mi
2. Patient Number
3. Date of Birth
H
__
Month
Day
Year
Gender
5.
4. Race
o 1. White
o 4. Asian
o 6. Other ________________________
o 1. Male
o 2. Black/African American
o 5. Native Hawaiian/Other Pacific Islander
o 2. Female
o 3. American Indian/Alaskan Native
Ethnicity: Hispanic Origin? o Yes o No
o 3. Transgender
6. County of Residence
7. Allergies:
DATE OF VISIT
______________________________
8a. Reason(s) for Visit
8b. Contact(s) verified by
(check all that apply):
9a. Prior STD/STI & Date Dx
9b. Vaccines & Testing
(Check at least one):
o STD Screen/Check
Hep B Vaccine
o Bacterial Vaginosis___________
o Partner notification card for
o Asymptomatic
___________________________
o No o Yes o Unk
o Symptomatic
o Chlamydia__________________
# injections _________________
o Referral Source _______________
o *Positive test for _________________
Last injection date :___________
o Genital Warts_______________
o NC EDSS event ID
o Referred by DIS or Health Care
o Verbalization of Partner/Contact
o Gonorrhea_________________
Twinrix Vaccine
Provider or ED
o No o Yes o Unk
o Medical Record of Partner/Contact
o HIV_______________________
o Contact to person treated for _______
____________________________
# injections _________________
Date Dx:___________________
o Exposed to partner with symptoms
____________________________
Last injection date :___________
____________________________
State/Country Dx:____________
o Other _________________________
Tdap Vaccine
o Herpes
o oral _____________
o No o Yes o Unk
o genital___________
Symptom Parameters
Last injection date :___________
Specify location, quality, severity, duration, frequency
o MPC______________________
and associated symptoms, if applicable. Document
HPV Vaccine
what the client did to relieve the symptoms and the
o No o Yes o Unk
o NGU______________________
Present
Absent
Symptom
effectiveness of the action.
# injections _________________
o PID_______________________
Itch
Last injection date :___________
o
o
o Syphilis____________________
Irritation
o
o
Prior HIV Test
Date Dx:___________________
o No o Yes o Unk
Pain
o
o
State/Country Dx:____________
Last test date :_______________
Discharge
o
o
Titer:______________________
HBV Status
Dysuria
o
o
o Trichomoniasis______________
o Unk o Acute o Chronic
(Date Dx) ___________________
Ulcer/Lesion
o Yeast______________________
o
o
HCV Status
o Other______________________
Rash
o
o
o Unk o Acute o Chronic
o None______________________
(Date Dx) ___________________
10. Sexual Risk Assessment
Date of last sexual encounter:
Sexual partners past 60 days:
11. For Women
Contraception:
_____________________________
# male ________ # female ________
o None
In last 2 weeks:
LMP: ______ /______ /______
Sites of client’s exposure
:
(last 60 days)
o Emergency Contraceptive Pill
o Regular o Irregular
# sexual encounters _____________
o Mouth o Penis o Vagina o Anus
o OCP
Frequency_________________
# with condom use ______________
Have you ever:
o Injectable
Last Pap: _____ /_____ /_____
Yes/No
Do you currently use:
Last given _______________
o Normal o Abnormal
o o Had sex with partner of the
Alcohol o No o Yes
o Implant
same sex
Douche: o Yes o No
Frequency ____________________
o o Had sex with a bisexual male
o Diaphragm
Frequency_________________
o o Had sex for drugs or money
o IUD
Injectable drugs o No o Yes
Last______________________
o o Had sex with intravenous
Are you pregnant?
o Tubal ligation
Last injection ________________
drug user
o Yes o No o Don’t know
o Condoms
o o Had sex with HIV(+) partner
Non-injectable drugs o No o Yes
Are you breastfeeding:
o Hysterectomy
_____________________________
o o Paid for sex
_____________________________
o Yes o No
o Other
o o Shared needles
13. Comments:
12. Other Pertinent History
(document additional information in comments)
Antibiotics:
Other present
Reviewed client’s self-history
(last 2 weeks)
medication(s):
form when used by agency:
o None o Yes
o None o Yes
o Yes o No o N/A
o *If client is returning for treatment/counseling, re-interview the client for changes and if history remains the same, check this box.
Signature/Title of Interviewer:
Signature/Interpreter:
Date:
Signature/Title of Provider if not the Interviewer:
Date:
DHHS 2808 (Revised Feb 2014)
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