Dutchess County Department Of Health Sexually Transmitted Disease Reporting-Std Reporting Form
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1Dutchess County
STD Reporting Form
Department of Behavioral & Community Health
rev:01/16
Communicable Disease Division
85 Civic Center Plaza - Suite 106, Poughkeepsie, NY 12601
Tel: (845) 486-3402
Fax: (845) 486- 3557
Last Name: ________________________ First Name: _______________________ Maiden Name: _______________
Address ______________________________________________________________ Contact ____________________
Male
Female
Transgender - Male to Female / Female to Male
Date of Birth ________________
Race/Ethnicity:
White
Black
Asian
Hispanic
Non-Hispanic
Unknown
Other: __________________
Marital Status:
Single
Married
Divorced
Separated
Unknown
Other: ______________________________
Occupation and/or Employer: __________________________________________ Employer Telephone________________________
Emergency Contact (Name & Relationship): _______________________________ Emergency Telephone _____________________
Exam Date: ___/___/___
Screening
Contact to STD
Symptoms/Date of First Symptom ___/___/___
Discharge
Lower Abdominal Pain
Rash
Bumps
Itching
Painful Urination
Abnormal Bleeding
Burning Sensation
Testicular Pain
Genital Warts
Other:________________________________________
Pregnant
No
Yes
Due Date ___________
TOP Date _______________
Miscarriage Date ______________
Father of the Baby (FOB): _________________________________________________
FOB Phone ___________________
Was HIV test offered at this visit?
Yes
Yes, but patient declined
No
Last HIV test done ____/____/____
Unknown
**Do NOT report HIV results on this form**
2010 NYS Law – Every person between the ages 13-64 should be offered an HIV test
CHLAMYDIA – MUST BE REPORTED WITHIN 5 DAYS OF POSITIVE LAB REPORT
Date of Test: ___/___/___
Laboratory: ________ Specimen Source:
Blood
Cervical
Urine
Rectal
Throat
Date of Treatment ____/_____/_____
Expedited Partner Therapy
No
Yes
Azithromycin (Zithromax) 1gm PO Single Dose OR
Doxycycline (Vibramycin) 100mg PO 2x/day x 7 days
Observed
Rx.
GONORRHEA: MUST BE REPORTED WITHIN 24 HOURS OF POSITIVE LAB REPORT
Date of Test: __/___/____ Laboratory: ___________ Specimen Source:
Blood
Cervical
Urine
Rectal
Throat
Date of Treatment: ____/_____/_____
Observed
Rx.
Ceftriaxone (Rocephin) 250mg IM Single Dose
AND Azithromycin (Zithromax) 1gm PO Single Dose
Ceftriaxone (Rocephin) 250mg IM Single Dose
AND Doxycycline (Vibramycin) 100mg PO 2x/day x 7 days
Azithromycin (Zithromax) 2gm PO Single Dose (must have Test of Cure in 1 week)
Cefixime 400mg PO Single Dose
AND Azithromycin (Zithromax) 1gm PO Single Dose (must have Test of Cure in 1 week)
Cefixime 400mg PO Single Dose
AND Doxycycline (Vibramycin) 100mg PO 2x/day x 7 days (must have Test of Cure in 1 week)
SYPHILIS: MUST BE REPORTED BY PHONE (845) 486-3402, FOLLOWED BY FAX WITHIN 24 HOURS (845) 486-3557
Secondary – plantar palmer or bilateral body rash
Diagnosis
Primary - Chancre
Early Latent
Latent
Hx. Of Syphilis
RPR______
FTA*
TPPA
IgG/CIA/EIA
CSF
Is Confirmatory Positive?
Yes
No
Date of Test: __________ Laboratory: ________ _________
Specimen Source:
Blood
Other
Date of Treatment: ____/_____/_____
Doxycycline (Vibramycin) 100mg PO 2x/day x 28 days
Observed
Rx.
Benzathine Penicillin 2.4million units IM Single Dose
Benzathine Penicillin 2.4million units IM x 3 Doses
Not Treated
Previous Hx of Tx date:
____/_____/_____
*FTA needs confirmation with TPPA or IgG
Reporting Physician: ______________________________________________
Date of Report: ___________________________
Physician Address:_______________________________________________
Telephone and Fax________________________
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