Confidential Std Morbidity Report Form PDF Details

The National STD Morbidity Report is a document published by the Centers for Disease Control and Prevention (CDC) that reports on sexually transmitted diseases in the United States. The CDC publishes this report annually, but they have made an exception to release information from 2010 due to new guidelines about reporting HIV cases. In order to offset this lack of data, we have compiled our own confidential STD morbidity report form from recent research findings and interviews with medical professionals.

The table holds information about the confidential std morbidity report form. Prior to fill out the form, it can be worth checking more about it.

QuestionAnswer
Form NameConfidential Std Morbidity Report Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesnegative std test results form pdf, std fillable results form, std results template, std test results template

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:

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