STI Case Reporting Form for Chlamydia and Gonorrhea.

Clinic Information.

Date:

Person Completing this form:

Health Provider:

Contact phone number/fax:

Your lab reported a communicable disease on the patient shown below and listed you as the provider. The Oregon Department of Human Services and Washington County require additional information. The fax cover sheet you have received references Oregon Law (ORS 433) that requires you to report this information. Please complete the form within 24 hours, or by the end of the next working day, and fax it back to our office at 503-846-3644. If you prefer you may call to report the required information. We appreciate your cooperation and prompt handling of this confidential report.

Patient Information — Please complete all information requested below.

1. Name:

Date Of Birth:

Gender:

Male

Female

Others

2. Home Address:

_____________________________________

Street

__________________________________________

City

____________________

Zip

Phone Number:_ - - __

Alternative #:____________________

3. PREGNANCY TEST RESULT:

N/A

Negetive

Unknown

Positive

5. TEST RESULT TYPE:	PREVIOUS HIV TESTING:	Yes	No	Unknown
Chlamydia Positive Result	Gonorrhea Positive Result	If yes, last result was?	POS	NEG	Unknown
Date:____________________	Date:____________________	Month of last test:____________________	Year of last test:____________________

6. REASON FOR EXAM:	DIAGNOSIS:	SITE(S):
Symptomatic	Asymptomatic	Cervix	Ocular
Routine Exam	Symptomatic-Uncomplicated	Vaginal	Urine
Test for Cure	Pelvic Inflammatory Disease (PID)	Urethra	Pharynx
Exposed to Infection	Ophthalmia /conjunctivitis	Rectum	Others:
Pregnant	Disseminated

7. GONORRHEA TREATMENT PLAN:	CHLAMYDIA TREATMENT PLAN:
Rocephin/Ceftriaxone 250mg IM x 1. Date:___________________	Azithromycin 1gm orally in a single dose. Date:___________________
PLUS:	OR:
Azithromycin 1gm orally in a single dose.	Doxycycline 100mg BID x 7 days: Date__________________ (contraindicated during pregnancy)

Alternative Treatment Regimens:	Alternative Treatment Regimens:
Cefixime 400mg orally in a single dose. Date:___________________	Amoxicillin 500mg orally tid X 7 days. Date:___________________
PLUS:
Azithromycin 1 gm orally in a single dose.

Other Treatments Date:___________________

_______________________________________

test of cure recommended at 1 month)

8. IF NOT TREATED YET — PATIENT NOTIFIED OF INFECTION:	Yes	No
Does the provider need assistance in contacting a client that has not responded for treatment?	Yes	No

9. PARTNER MANAGEMENT PLAN — Ensuring Partner Treatment:

Expedited Partner Therapy dispensed at time of visit?	NO	YES: How many partners? _______________
See: OHA/STD Prevention for EPT guidelines and policy).

When resources allow the health department will be contacting gonorrhea cases and high risk chlamydia cases to offer partner services. Please notify patient that public health worker may be contacting them to offer partner services.
PROVIDER REQUESTS THAT CLIENT NOT BE CONTACTED BY PUBLIC HEALTH/PROVIDER WILL ASSURE PARTNER TREATMENT.

STI Case Reporting Form for Chlamydia and Gonorrhea.

Clinic Information.

Date:

Person Completing this form:

Health Provider:

Contact phone number/fax:

Patient Information — Please complete all information requested below.

1. Name:

Date Of Birth:

Gender:

2. Home Address:_____________________________________

Street

__________________________________________

City

____________________

Zip

Phone Number:_______ - ________- ________

Alternative #:____________________

3. PREGNANCY TEST RESULT:

N/A

Negetive

Unknown

Positive

4. ETHNICITY:

Hispanic

Non-hispanic

Unknown

Race:

White

Black

Asian

American Indian

Alaskan

Pacifc Islander

Unknown

Others:______________

GENDER OF SEX PARTNER(S):

Male

Female

Both

5. TEST RESULT TYPE:

PREVIOUS HIV TESTING:

Yes

No

Unknown

Chlamydia Positive Result

Gonorrhea Positive Result

If yes, last result was?

POS

NEG

Unknown

Date:____________________

Date:____________________

Month of last test:____________________

Year of last test:____________________

6. REASON FOR EXAM:

DIAGNOSIS:

SITE(S):

Symptomatic

Asymptomatic

Cervix

Ocular

Routine Exam

Symptomatic-Uncomplicated

Vaginal

Urine

Test for Cure

Pelvic Inflammatory Disease (PID)

Urethra

Pharynx

Exposed to Infection

Ophthalmia /conjunctivitis

Rectum

Others:

Pregnant

Disseminated

7. GONORRHEA TREATMENT PLAN:

CHLAMYDIA TREATMENT PLAN:

Rocephin/Ceftriaxone 250mg IM x 1. Date:___________________

Azithromycin 1gm orally in a single dose. Date:___________________

2. Home Address:

_____________________________________

Phone Number:_ - - __