"Sti Report Form"

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Clinic:
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:
www.FreePrintableMedicalForms.com
Clinic:
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:
www.FreePrintableMedicalForms.com