Houston Department Of Health And Human Services, Confidential Std Morbidity Report Form
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1CONFIDENTIAL STD MORBIDITY REPORT FORM
Houston Department of Health and Human Services
th
ATTN: Bureau of Epidemiology – STD Surveillance 4
floor
8000 North Stadium Drive
Houston, Texas 77054
Tel: (832)393-5080
Fax: (832)393-5233
Reported by:
Facility/Clinic:
Phone Number:
Date:
PATIENT DEMOGRAPHIC DATA
Last Name
First Name, MI
DOB
Social Security #
Sex
Race
Hispanic
Y
N
Address
Home Phone
(
)
--
City, State Zipcode
Other Phone
(
)
--
Emergency Contact Name
Contact Phone
(
)
--
Marital Status
Single
Married
Divorced
Widowed
Unknown
Pregnancy Status
N/A
No
Yes (
___/___/___)
Unknown (L
___/___/___)
Expected delivery date
ast menstrual date
Reason for Test (STD related, prenatal;, immigration, etc):
DISEASE DATA
Check Reportable Disease(s)
Syphilis
Gonorrhea
Chancroid
Chlamydia
List Signs and Symptoms:
Check Voluntary Disease(s)
Genital Warts
Non-specific Urethritis
Pelvic Inflammatory Disease
s
Genital Herpe
Trichomoniasis
Other non-specific Vaginitis
Mucopurulent Cervicitis
Other _________________
LABORATORY DATA
Date of Collection/Test
Diagnostic Test
Results
Laboratory
TREATMENT INFORMATION
Prior History of Treatment
Yes
No
Unknown
Date of Previous Treatment _____/_____/_____
Method of Prior Treatment_________________
CURRENT TREATMENT INFORMATION:
Date (s) of Treatment
Method of Treatment / Dose
Provider
Notes/Comments/Patient History/Risk Factors:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
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