Confidential Std Morbidity Report Form PDF Details

When it comes to managing and tracking sexually transmitted diseases (STDs), confidentiality and accuracy are paramount. One such tool at the forefront of this delicate balance is the Confidential STD Morbidity Report Form, utilized by the Houston Department of Health and Human Services. This critical form serves multiple purposes: it records detailed patient demographic data, captures specific disease data for reportable STDs such as Syphilis, Gonorrhea, Chlamydia, and Chancroid, and notes voluntary disease information which includes ailments like Genital Herpes and Pelvic Inflammatory Disease. It doesn't stop there; the form also delves into laboratory data, current and prior treatment information, ensuring that every aspect of the patient's condition and care is thoroughly documented. The information captured not only aids in the patient's treatment but also contributes to public health surveillance efforts, helping the Bureau of Epidemiology in STD Surveillance to track, manage, and ideally reduce the spread of these diseases. This blend of patient care with public health initiatives underscores the form’s vital role in healthcare management within communities.

QuestionAnswer
Form NameConfidential Std Morbidity Report Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesconfidential std morbidity form, std results pdf template, blank std test result templates, negative std test results form pdf

Form Preview Example

CONFIDENTIAL STD MORBIDITY REPORT FORM

Houston Department of Health and Human Services

 

 

 

 

ATTN: Bureau of Epidemiology – STD Surveillance 4th 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 (Expected delivery date___/___/___)

… Unknown (Last menstrual date___/___/___)

 

 

 

Reason for Test (STD related, prenatal;, immigration, etc):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISEASE DATA

 

 

 

 

 

 

 

 

 

 

 

 

 

Check Reportable Disease(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

… Syphilis

 

… Gonorrhea

… Chlamydia

 

 

 

… Chancroid

 

 

 

 

List Signs and Symptoms:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check Voluntary Disease(s)

… Genital Warts

… Non-specific Urethritis

 

… Pelvic Inflammatory Disease

 

 

 

 

…Genital Herpes

 

 

 

 

 

… 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 _____/_____/_____

 

 

 

CURRENT TREATMENT INFORMATION:

Method of Prior Treatment_________________

 

 

 

 

 

 

 

 

 

 

Date (s) of Treatment

 

Method of Treatment / Dose

 

Provider

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes/Comments/Patient History/Risk Factors:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

How to Edit Confidential Std Morbidity Report Form Online for Free

It won't be challenging to get std paperwork through our PDF editor. Here's how you will be able rapidly develop your template.

Step 1: The web page has an orange button that says "Get Form Now". Please click it.

Step 2: You will discover all of the options you can take on your document when you have entered the std paperwork editing page.

Complete the following segments to prepare the file:

part 1 to writing std test template

Type in the information in the cid Trichomoniasis, cid Other nonspecific Vaginitis, cid Other, Date of CollectionTest, Diagnostic Test, Results, Laboratory, LABORATORY DATA, TREATMENT INFORMATION, Prior History of Treatment cidYes, CURRENT TREATMENT INFORMATION, Date of Previous Treatment Method, Date s of Treatment, Method of Treatment Dose, and Provider area.

std test template cid Trichomoniasis, cid Other nonspecific Vaginitis, cid Other, Date of CollectionTest, Diagnostic Test, Results, Laboratory, LABORATORY DATA, TREATMENT INFORMATION, Prior History of Treatment cidYes, CURRENT TREATMENT INFORMATION, Date of Previous Treatment Method, Date s of Treatment, Method of Treatment Dose, and Provider fields to fill

Jot down the expected data when you find yourself within the NotesCommentsPatient HistoryRisk part.

Completing std test template part 3

Step 3: Press "Done". You can now transfer the PDF document.

Step 4: You will need to create as many copies of your form as you can to remain away from possible issues.

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