Confidential Sexually Transmitted Disease (Std)/hiv Report Form - State Of Alaska, Section Of Epidemiology
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1Confidential Sexually Transmitted Disease (STD)/HIV Report Form
State of Alaska, Section of Epidemiology
Health care providers may use this form to make STD/HIV reports. Please use the Infectious Disease Report Form to report
other infectious diseases. Forms may be found at
Patient Information
Last Name _____________________________________ First Name______________________________ MI _______
Date of birth ____/____/______
Sex:
Female
Pregnant:
No
Yes; # of weeks ________
Unknown
(mm/dd/yyyy)
Male
Gender of Sex Partners:
Male
Female
Unknown
Transgender
(check all that apply)
Race:
White
Asian
Ethnicity:
Hispanic
Black
Unknown
Non-Hispanic
Alaska Native/American Indian
Other __________
Unknown
Native Hawaiian/Pacific Islander
Physical Address __________________________________________________
PO Box ___________________
City ______________________________________ State_______
Zip Code ___________________
Phones (home) _______________________ (cell) _____________________
(work) ___________________
Disease Information
CHLAMYDIA
GONORRHEA
SYPHILIS
HIV
Complications:
Pelvic Inflammatory Disease (PID)
Epididymitis
Congenital infection
Disseminated Gonococcal Infection (DGI)
Conjunctivitis
Other _______________________
Was the diagnosis laboratory confirmed?
Yes
No
Specimen collection date: ____/____/______
Type of Specimen:
Urine
Serum RPR
HIV EIA Ag/Ab Combo
Vaginal swab
Serum FTA
HIV Multispot Type 1 Positive
Urethral/Cervical swab
Rapid HIV __ oral __ serum
HIV Multispot Type 2 Positive
Pharyngeal swab
HIV P24 Antigen Screen
HIV Western blot
Rectal swab
HIV EIA
Other: __________________________
Name of Medical Facility ______________________________________________ Phone ___________________________
Attending health care provider _________________________________ Laboratory Name (if known) ____________________
Treatment Information (Chlamydia, Gonorrhea and Syphilis Only)
Was treatment prescribed?
Yes
No Date ____/____/______
Pharmacy (if known) _______________________
Medication:
Azithromycin (Zithromax) _____1 gm ____ 2
gm……
Directly Observed Therapy?
Yes
No
…………………………
Cefixime (Suprax) 400 mg PO
Directly Observed Therapy?
Yes
No
Rocephin (Ceftriaxone) IM ____250 mg ____Other _____ (mg/g)
Doxycycline PO BID ____7 days ____10 days ____14 days
Benzathine Penicillin G 2.4 mu IM ____ 1 dose ____ 3 doses
Other Medication: _____________________________ Dosage: _________________________ # Days: ______________
Other Medication: _____________________________ Dosage: _________________________ # Days: ______________
Was EPT (Expedited Partner Therapy) provided for sexual partner(s)?
No
Yes # Doses ___________
Reported by: ____________________________________________________ Date Reported: ____/____/_____
Fax reports to (907) 561-4239 – please verify fax has been transmitted.
Rev 03/2016
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