Sexually Transmitted Diseases (Std) Case Report - Department Of Health - Std/aids Prevention Program - 2013
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1STATE OF HAWAII
For official use only:
C
Department of Health
ase No:______________DIS#_____
[ ] STDMIS [ ] INTERVIEW
STD/AIDS Prevention Program
[ ] FIELD
[ ] CONTACT Follow-up
Sexually Transmitted Diseases (STD) Case Report
Please complete this form to report Sexually Transmitted Diseases.
Patient’s Last Name: _________________________ First Name _______________________ M.I. _____ AKA: _____________________
Date of Birth ____________ Age _____ Sex:
Family Planning?
( )Transgender ( )Male ( )Female:
( )Yes ( )No
Pregnant? ( )No ( )Yes ____gestation wks
Race ______________________
Ethnicity:
Marital Status:
( )Hispanic ( ) Non-Hisp
( )Single ( )Married ( )Separated ( )Divorced ( )Widowed
Address: ______________________________________ City ______________ State ____ Zip Code _________ Phone: ___________
Physician: ____________________________ Address: ________________________________________________ Phone: ___________
I. PATIENT DIAGNOSIS AND TREATMENT: Refer to the CDC 2010 Sexually Transmitted Diseases Treatment Guidelines for alternative regimens and more information.
DATE OF TEST/
DISEASE/DIAGNOSIS
TREATMENT
DIAGNOSIS
CHANCROID
TREATMENT DATE ______/_____/_____
[ ] Azithromycin 1g po
[ ] Ciprofloxacin 500 mg po bid x3d
[ ] Ceftriaxone 250 mg IM
[ ] Erythromycin base 500mg po tid x 7 days
________________________________________________________
Other (specify):
PELVIC INFLAMMATORY
TREATMENT DATE ______/_____/_____
DISEASE
Either [ ] Ceftriaxone 250 mg IM, or
[ ] Cefoxitin 2g IM with Probenecid 1g po
[ ] Chlamydia
Plus
[ ] Doxycycline 100 mg po bid x 14 days
[ ] Gonorrhea
Other (specify):________________________________________________________________________
[ ] Unspecified
CHLAMYDIA
TREATMENT DATE ______/_____/_____
TRACHOMATIS
[ ] Azithromycin 1g po single dose
[ ] Doxycycline 100 mg po bid x 7 days
[ ] PID (use PID section)
________________________________________________________
Other (specify):
[ ] Uncomplicated
GONORRHEA
TREATMENT DATE ______/_____/_____
[ ] PID (use PID section)
Either [ ] Ceftriaxone 250 mg IM, or [ ] Cefixime 400 mg po single dose, or
[ ] Pharyngeal
[ ] Single dose injectable cephalosporin (specify type/dose): _____________________________
[ ] Uncomplicated
Plus
[ ] Azithromycin 1g PO single dose Stat
________________________________________________________
Other (specify):
Dual treatment is recommended to mitigate emergence of cephalosporin resistant gonorrhea. Flouroquinolone is not recommended
for the treatment of gonorrhea infections. If gonorrhea is documented and symptoms persists or recurs, test-of-cure culture is
recommended to ensure patient does not have an untreated antibiotic resistant gonorrhea infection. Please call SPP immediately at
(808) 733-9281 or after hours, (808) 224-1389, to report suspected case of treatment failure or patients whose isolates demonstrate
decreased susceptibility to cephalosporin.
SYPHILIS
TREATMENT DATE ____/_____/_____
[ ] Primary
[ ] Benzathine penicillin G, 2.4 million units IM in a single dose
[ ] Secondary
_______________________________________________________
Other (specify):_
[ ] Early Latent
(<1 year duration)
[ ] Late, Late Latent
TREATMENT DATES #1____/_____/_____
#2____/_____/_____
#3____/_____/_____
[ ] Gumma
[ ] Benzathine penicillin G, 7.2 million units total, administered as 3 doses of 2.4 million units IM, at 1-week intervals
[ ] Cardiovascular
_______________________________________________________
Other (specify):_
[ ] Neurosyphilis
TREATMENT DATE ____/_____/____
[ ] Aqueous crystalline penicillin G, 18-24 million units daily, administered as 3-4 million units IV q4hrs x 10-14 days
_______________________________________________________
Other (specify):_
II. REQUEST TO TREAT PATIENT. If physician requests that DOH treat patient for this infection, please indicate treatment to be provided and sign as indicated.
[ ] Azithromycin 1g PO [ ] Cefixime 400 mg PO
Physician’s Name: (PRINT) ____________________________________________Signature: _________________________________________________Date_____________
III. LIST CASUAL AND/OR STEADY SEX PARTNERS THE PATIENT HAD IN PAST 60 DAYS.
Date of
Last
For
Was sex partner
Refer to DOH
Marital
DOH
Name/Address/Phone
Birth/
Race
Sex
Exposure
Use
Status
Interview/
Age
Dates
Examined?
Infected?
Treated?
Treat
only
Notify SP
Unknown
Unknown
Unknown
No
No
No
No
No
Yes:
Yes:
Yes: Date
Yes
Yes
Date
Dx
Rx
Unknown
Unknown
Unknown
No
No
No
No
No
Yes:
Yes
Yes: Date
Yes
Yes
Date
Dx
RX
IV. THE FOLLOWING ARE AVAILABLE FROM THE DOH AT NO CHARGE. Indicate quantity and FAX order to (808)- 733-9291.
[
] Pamphlets on STD/HIV/AIDS.
Foreign language translations are available. Foreign Language(s): ________________
Quantity:_____
[
] 2010 Sexually Transmitted Diseases Treatment Guideline
[
] Case Report Forms
For consultation regarding STDs, please call (808) 733-9281.
V. CALL, MAIL OR FAX REPORT TO:
Oahu: Hawaii STD Prevention Program
Kauai: Epidemiology Branch
Big Island: Epidemiology Branch
Maui, Lanai, Molokai: Epidemiology Branch
3627 Kilauea Avenue, Room 304
3040 Umi Street
191 Kuawa St.
54 High Street
Honolulu, HI 96816
Lihue, HI 96766
Hilo, HI 96720
Wailuku, HI 96793
Phone: (808) 733-9281
Phone: (808) 241-3563
Phone: (808) 974-4247
Phone: (808) 984-8213
FAX:
(808) 733-9291
FAX: (808) 974-4243
MrbdJan2013
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