Local Health Department
Sexually Transmitted Disease Clinic
Address
Phone and Fax
List & describe reaction:
Antibiotics taken within last 4 weeks? o No o Yes
Name ______For
Chronic Meds: ______Used For:
Vaccine Hx: Hep A ___ Hep B ___ HPV ___ / Date: ______Legal Name: ______
Preferred Name:______DOB: ______Race: ______Birth assigned sex: (M / F / I) ______
Gender (all that apply) M F Trans Self-define:______
MEDREC NO: ______
REASON FOR EXAM:
o Checkup
o DIS Referral
o Contact Card/Partner Ref.
o Partner in clinic: ______DX
o F/U
o HIV Testing only
o Lab only -
o Provider/agency Referral
o HPV TX #
o Other
If Seen within 30 days:
Persistent symptoms o Yes o No
Partner(s) treated oYes oNo oUnknown
Notes:
/ PATIENT HX/SYMP:
NO YES
o o Discharge/Color
o o Burning
o o Lesions/Blisters/Bumps
o o Rash
o o Itching
o o Odor
o o Pain
o o Swelling
o o Partner w/symptoms
Travel past 60 days
Notes
/ SEXUALLY ACTIVE WITH:
o MEN o WOMEN o BOTH
# of sex partners in last 60 days? ____
If only one, how long ______?
Date of last sexual contact? ______
Exposure site:
P/V RECTAL ORAL
o o Receptive o Receive
o Insertive o Give
Condoms Used last contact?
o NO o YES o BROKEN
Condoms used ______% of time
HIV RISK ASSESSMENT (If yes, list date)
NO YES
o o Used IV drugs
o o Had sex with an IVDU
o o Traded sex for drugs or money?
o o Sex with an HIV+ partner?
o o Victim of child abuse/Rape/Assault
o o Used apps/soc media to find partners
o o IPV/Human trafficking
o o Prior HIV test Date : ______
o POS o NEG
o o “Street” tattoos
o o History of incarceration / PREVIOUS DX: Year
o None
o Gonorrhea ______
o Chlamydia ______
o Syphilis ______
o Alcohol Use: #drinks/day______
o Smoking ______
□ Substance use ______/ CONTRACEPTION:
o NONE o HORMONAL ______
o BTL o IUC Other: ______
LMP ______o WNL o ABNL ______
Pregnant: o No o Yes:
EDC____ o UNK
G: ____ P: ______AB: ______
Last Pap: ____ o WNL o ABNL ___
Remarks:______
______
Douching: o No o Yes Freq.:______
CLINICAL DIAGNOSIS/IMPRESSION
o No disease o PID-etiology o Molluscum o Epi treat
Pending results unknown Gonorrhea
o IUP/ +Preg Test o Syphilis (700) o Herpes simplex o Epi treat
Chlamydia
o Chlamydia (200) o Serofast/Decreasing o Pediculosis Pubis o Epi treat
RPR titer (705) Trichomonas
o Gonorrhea (300) o Primary (710) o Scabies o Epi treat other
syphilis ______
o Non-gonococcal o Secondary (720) o Tinea/fungus o Other
Urethritis syphilis ______
o Mucopurulent o Early latent (730) o UTI o Immunization HepAB HPV
Cervicitis syphilis (<1yr)
o Bacterial o Late latent (745) o Folliculitis
Vaginosis syphilis (>1 yr)
o Trichomoniasis o HPV o HIV + (900) PATIENT DECLINES
FOLLOWING TESTS:
o Candidiasis o Epi treat
(yeast) Syphilis PATIENT SIGNATURE: ______
Clinician Signature: ______Date: _____/______/_____
GENERAL PHYSICAL EXAM: o NOT DONE o GENITAL ONLY
Oro-pharynx Skin Nodes Rectal Pubic Hair Penis Scrotal Contents
o WNL o WNL o WNL o Not Done o WNL o WNL o WNL
o Ulcer o P & P Rash o Cervical o WNL EXT) o Crabs/nits o Uncirc o Left
o Exudate o Other Rash o Axillary o Warts o Other o D / C o Right
o Vesicles o Folliculitis o Inguinal o D / C o Ulcer o Tender o Right o Left
o Inflamed o Molluscum o Epitrochlear o Ulcer o Vesicle o Swollen o Right o Left
o Other o Scabies o Enlgd o Left o Vesicle o Warts o Mass o Right o Left
o Vesicles o Right o Other o Balanitis o Hydrocele o Right o Left
o Rash o Other
Vulva/Vagina Cervix Uterus Adnexa o Molluscum
o WNL o WNL o WNL o WNL o Other
o Erythema o Ectopy o Tenderness o Mass
o Abnl. D / C o Discharge o Other o Left
o Ulcer o Friable o Right
o Vesicle o Ulcer o Tenderness
o Warts o Vesicle o Left
o Rashes o CMT o Right
o Menses o Other o Other
o Other
o PH o Whiff
Notes:
Stat Lab
RPR HIV
SHC UPT
Wet mount ______
Gram Stain ______
Patient Education:o Avoid sexual contact for ______days
o Handouts given
o Medication instructions/side effects given
o Pregnancy counseling & referral
o Referral for well woman/Pap/Birth control
o Abstain from alcohol x ______days
o Safer sexual practices discussed
o Social media / phone apps
o Skin care instructions
o Patient-Delivered Partner Therapy HO
o Other: ______
o Smoking cessation
o Alcohol / substance abuse / Disposition/Referral:
o DIS Referral
o Contact Cards
o Lab Results Available Date:
o Return Appointment Date:
o Referral
o Immunizations
o Other
o PENDING LAB
Oral GC Culture ____ HSV Culture____
Rectal GC Culture ____ Hep C ____
Other ____ / DIS ACTIVITY:
o Interviewed patient
o STD/HIV PC/PE counseling
o Record Search
o Other:
Name ______DIS#
TREATMENT:
o None
o Bicillin LA 2.4 MU IM #1 #2 #3 Site ______Time ______
o Azithromycin 1 GM
o Azithromycin 2 GMs
o Ceftriaxone 250 MG IM Site ______Time ______
o Cefixime (Suprax) 400 MG PO STAT
o Doxycycline 100 MG PO BID X 7 d x 14 d 21 d
o Partner Delivered Therapy (Azithromycin 1gm) ______packs
o Partner Delivered Therapy (Suprax 400mg) ______packs
o Metronidazole 2 GM PO STAT
o Metronidazole 500 MG PO BID X 7 d
o Acyclovir ______Refills ______/ o Liquid Nitrogen
o Trichloracetic Acid (TCA)
o Aldara use as directed 3x/wk
o Diflucan 150MG, 1 TAB, PO
o Clotrimazole 1% AF/VAGINAL CREAM
o Miconazole 2% VAGINAL CREAM
o OTC Antifungal Cream
o Lindane 1% Lotion / Shampoo
o Permethrin (Elimite) 5% CREAM
o Bactrim DS 160/800mg PO BID x 4 days
o HPV Vaccine #1 #2 #3 Site ______Time ______
o Hepatitis B Vaccine #1 #2 #3 Site ______Time _____
o Other ______
CLINICIAN SIGNATURE: ______Date: ______
Adapted from Austin-Travis County Health Department - 2014