Sti Report Template
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1Clinic:
Address:
STI Report Form
Phone:
Case #:
Patient Information
Name:
DOB:
Age:
Height:
Weight:
Race:
Sex:
Address:
Email:
Phone:
Medical History
Currently Pregnant?
Yes
No
Estimated Due Date:
Date of Last Menstrual Cycle:
Length of Cycle:
Birth Control Method:
Marital Status:
Symptoms
Cloudy/Bloody Discharge
Strong Vaginal Odor
Fever
Sore Throat
Yellow/Green Discharge
Vaginal Itching/Irritation
Aching Joints
Headache
Painful Urination
Penile Itching/Irritation
Weight Loss
Rash
Painful/Swollen Testicles
Anal Itching
Abdominal Pain
Swollen Lymph Nodes
Painful Bowel Movements
Abnormal Menstruation
Painful Sores
Fatigue
Painful Intercourse
Testicular Pain
Non-Painful Sores
Diarrhea
Other Symptoms:
Symptom(s) Start Date:
Symptom Frequency:
Irregular
Constant
Regular
Intermittent
Specimen Source:
Cervix
Throat
Blood
Lesion
Rectum
Genitalia
Urethra
Diagnosis
Syphilis
Chlamydia
Gonorrhea
Trichomoniasis
HPV
HIV
Genital Herpes
Pubic Lice
Chancroid
Scabies
Hepatitis
Other
Other:
Diagnosing Doctor:
Facility:
Date Reported:
Lab Confirmed?
Lab Name:
Collection Date:
Test Type:
Test Results:
Treatment
Treatment Administered:
Date:
Dosage:
Medication Prescribed:
Frequency:
Dosage:
EPT Provided For Partner?
Date:
Dosage:
Treatment Prescribed by:
Phone:
Medication Prescribed by:
Notes
Physician Notes:
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Parent category: Business