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FAX Page 1 To: Public Health – Seattle & King County STD Program 206 744-5622 (Confidential FAX Line)

www.kingcounty.,gov/health/std

CONFIDENTIAL SEXUALLY TRANSMITTED DISEASE CASE REPORT

Report STDs within three work days (WAC 246-101-101/301).

LAST NAME

PATIENT INFORMATION FIRST NAME

MIDDLE INITIAL

ADDRESS

CITY/TOWN

STATE

TELEPHONE () ZIP CODE

REASON FOR EXAM (Check one) Symptomatic

Routine Exam – No Symptoms Exposed to Infection

DATE OF DIAGNOSIS

SEX

DATE OF BIRTH

MO ETHNICITY Hispanic

Non-Hispanic Unknown

DAY

YR Male RACE – Check all that apply

Female

White Black

Asian Other

Unknown American Indian/Alaskan Native

Native Hawaiian/Other Pacific Islander DIAGNOSIS – DISEASE

MO DAY GENDER OF SEX PARTNERS

Male

Both

Female

Unknown

YR

DIAGNOSIS - a only one

GONORRHEA (lab confirmed)

SITE(S) - a all that apply

TREATMENT - a all prescribed

SYPHILIS Primary (Chancre, etc.)

Asymptomatic Symptomatic-Uncomplicated Pelvic Inflammatory Disease Ophthalmia Disseminated Other Complications: __________

DATE TESTED: _________________

Cefpodoxime

Ceftriaxone

Doxycycline

Azithromycin

Levofloxacin*

Ciprofloxacin*

Cefixime

Other

Cervix Urethra Urine Rectum Pharynx Ocular Other: _______________________ Other: _______________ ____________________ DATE RX:

Secondary (Rash, etc.) Early Latent (<1 yr) Late Latent (>1 yr) Congenital Late Neurosyphillis

RX GIVEN:

________________

DATE RX: _________________

DIAGNOSIS - a only one

CHLAMYDIA TRACHOMATIS (lab confirmed)

SITE(S) - a all that apply

TREATMENT - a all prescribed

HERPES SIMPLEX Genital (initial infection only)

DATE TESTED: Asymptomatic Symptomatic-Uncomplicated Pelvic Inflammatory Disease Ophthalmia Other Complications: __________ _________________

Cervix Rectum Urethra Pharynx Urine Ocular Other: DATE RX: Azithromycin Doxycycline Levofloxacin Other: _______________ ______________ _______________ Lymphogranuloma Venereum Erythromycin Ofloxacin Yes Neonatal Laboratory Confirmation Chancroid Granuloma Inguinale No OTHER

PARTNER MANAGEMENT PLAN a Select method of ensuring partner treatment

1.

2. 3.

Health Department to assume responsibility for partner treatment. Health Department assistance recommended if: Patient has had 2 or more sex partners in the last 60 days, or Patient does not think he/she will have sex again with sex partners from the last 60 days, or Patient is unable or unwilling to contact one or more partner, or Patient is a man who has sex with other men. Note: You may also choose this option if you are providing partner treatment for one or more partners (free meds available) and would like Health Department assistnance for additional partners. If providing partner treatment, indicate number of partners treated ( Partner Plan Instructions Next Page _________ ). Provider will ensure all partners treated (FREE medications available). Indicate number to be treated ( ________

All partners have been treated. Indicate number treated (

________

).

).

DATE

REPORTING CLINIC INFORMATION DIAGNOSING CLINICIAN

FACILITY NAME

PERSON COMPLETING FORM

ADDRESS

TELEPHONE

CITY

STATE

FAX #

Thank you for reporting an STD. All information will be managed with the strictest confidentiality.

PRIVILEGED AND CONFIDENTIAL COMMUNICATIONS: The information contained in this message is privileged, confidential, or otherwise exempt from disclosure and is intended solely for the use of the individual(s) named above. If you are not the intended recipient, you are hereby advised that any dissemination, distribution, or copying of this communication is prohibited. If you have received this facsimile in error, please immediately notify the sender by telephone and destroy the original facsimile. (04/09) P 1

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