Illinois Confidential Morbidity Report Of Sexually Transmitted Diseases Form - Illinois Department Of Public Health
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2IL L IN O IS D E P A R T M E N T O F P U B LIC H E A L T H
IL L IN O IS C O N F ID E N TIA L M O R B ID IT Y R E P O R T O F S E X U A L L Y TR A N S M IT T E D D IS E A S E S
392
4 . Print capital letters and
1 . P rin t
2 . O n ly u se
S e n d
5 . F ill in
L IK E T H IS :
3 .
N O T :
A B C D
n u m b e rs co m p le te ly
firm ly a n d
p e n w ith
o rig in a l
c irc le s
Mark your MISTAKES like this:
in sid e b o xe s:
n e a tly.
d a rk in k.
fo rm .
Expedited Partner Therapy
PATIENT INFORMATION
FIRST NAME
M.I.
Expedited Partner Therapy given to
patient with chlamydia and/or gonorrhea
for partner(s).
Yes
No
Unknown
LAST NAME
IDOC #
If yes, for how many partners?
STREET ADDRESS
APARTMENT NUMBER
CITY
STATE
ZIP CODE
LOCAL NUMBER
AREA CODE
P H O N E
(
)
I L
-
-
N U M B E R
COUNTY OF RESIDENCE
DATE OF BIRTH
AGE (Years)
/
/
SEX
PREGNANCY
RACE (Check All That Apply)
ETHNICITY
White
Native Hawaiian or Other Pacific Islander
Hispanic or Latino
Yes
No
Male
/
/
Black or African American
American Indian or Alaskan Native
Not Hispanic or not Latino
Est.Due Date
Female
Asian
Unknown
Other
Unknown
DIAGNOSIS
Chlamydia
Syphilis
Gonorrhea
Other STDs
Genito-urinary
Rectal
Primary
Genito-urinary
PID
Chancroid
Late symptomatic
LGV
Ophthalmia
DGI
Congenital
Secondary
Ophthalmia
DATE OF TEST/EXAM
Pneumonia
Pharyngeal
PID
Early latent (<1 Yr.)
Neurological Involvement
/
/
Confirmed (positive CSF-VDRL)
Other:
Other:
Latent (unk. duration)
Probable
Late latent (>1 Yr.)
LABORATORY TEST(S) RELATED TO DIAGNOSIS
Chlamydia Test
Gonorrhea Test
Syphilis Tests
Serologic Screening Test: RPR, VDRL
DATE POSITIVE TEST COLLECTED
DATE POSITIVE TEST COLLECTED
R E S U L T
/
/
/
/
/
/
Pos
DATE OF TEST
Neg
1 :
T ite r
TREATMENT (RX) INFORMATION (See reverse side for treatment codes)
Serologic Confirmatory Test: FTA-ABS, TP-PA, EIA
Date(s) Treated
RX Codes
Other
R E S U L T
Pos
/
/
DATE OF TEST
/
/
Neg
Darkfield / DFA-TP (from lesion)
R E S U L T
Pos
/
/
/
/
DATE OF TEST
Neg
R E S U L T
CSF-VDRL
/
/
Pos
/
/
DATE OF TEST
Neg
F A C IL IT Y WHERE SPECIMEN WAS COLLECTED
FACILITY WHERE TREATEMENT WAS PROVIDED
N a m e
N a m e
A d d re s s
A d d re s s
C ity
P h o n e
P h o n e
C ity
N a m e o f P e rso n C o m p le tin g F o rm
If you wish assistance in sex partner referral, need additional forms, etc., call your local health department STD Program.
Illin o is D e p a rtm e n t o f P u b lic H e a lth
C h ic a g o D e p a rtm e n t o f P u b lic H e a lth
If TESTING fa c i l i ty i s l o c a te d
If TESTING fa c i l i ty i s
A T T N : S T D P ro g ra m
A T T N : S T D P ro g ra m
l o c a te d w i th i n
o u ts i d e C h i c a g o c i ty l i m i ts ,
2045 West Washington
5 2 5 W . J e ffe rso n S t.
C h i c a g o c i ty l i m i ts ,
s u b m i t re p o rt to y o u r l o c a l h e a l th
C h ic a g o , IL 6 0 6 12
S p rin g fie ld , IL 6 2 7 6 1
If no local health
s u b m i t re p o rt to:
d e p a rtm e n t.
Phone: 3 1 2 -413-8047; Fax:312-355-1915
2 1 7 -7 8 2 -2 7 4 7
department, submit report to:
T T Y (h e a rin g im p a ire d u se o n ly) 8 0 0 -5 4 7 -0 4 6 6
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