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Report For information and epidemiologic assistance call: 287-3747 FAX this completed form to STD Surveillance: 287-3498  \n\n| Patient's Name: Patient Phone: |  |  |  | Date of Report: |  |\n| --- | --- | --- | --- | --- | --- |\n| Patient Address |  |  |  | DOB |  |\n| City or Town State Zip |  |  |  | Sex\u003Cbr>  Male   Female |  |\n| Race (check all that apply)  White   Black/Af Am  Am Ind/Ala Nat  Asian   Nat Haw/Pac Islander  Two or more races   Some other race |  | Disease (check all that apply)   Gonorrhea\u003Cbr>  Chlamydia\u003Cbr>  Chancroid\u003Cbr>  Syphilis (check stage) Primary____Secondary_____Early Latent  Late Latent    Other |  | Patient Marital Status:\u003Cbr>  Single   Married\u003Cbr>  Separated   Divorced\u003Cbr>  Domestic Partner   Widowed |  |\n|  |  |  |  | Check if you need:\u003Cbr>  Health Department Assistance |  |\n| Ethnicity\u003Cbr>  Hispanic/Latino   Non-Hispanic/Latino |  |  |  |  |  |\n| Reporting Physician: |  |  |  | Report Completed by: |  |\n| Physician Address: |  |  |  | Physician Phone: |  |\n| Reason for Exam (check all that apply)\u003Cbr>  Pre-natal\u003Cbr>  Routine Screen   Contact\u003Cbr>  Symptomatic If yes, how long? |  |  |  | Is Patient Pregnant?\u003Cbr>  Yes   No\u003Cbr>How many weeks?   |  |\n|  |  |  |  | Treatment\u003Cbr>Was Patient Treated for Infection(s)\u003Cbr> Yes   No |  |\n| Lab Name  Lab Phone  |  |  |  |  |  |\n| Date | Type of Test (Serology, Urine, DNA Probe) |  | Results | Medication Used and Amount | Date |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n\n\n| Partner Information (if known) |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Partner Name: Partner Phone: DOB |  |  |  |  |\n| Partner Address |  |  | Race (check all that apply)\u003Cbr> White   Black Af/Am   Asian  Am Ind/Ala Nat   Nat Haw/Pac Isl  Two or more races   Some other race |  |\n| City or Town State Zip |  |  |  |  |\n|  |  |  | Ethnicity\u003Cbr>  Hispanic/Latino\u003Cbr>  Non-Hispanic/Latino |  |\n| Partner was : Tested   Yes   No\u003Cbr>Partner was : Treated   Yes   No |  |  |  |  |\n| Date | Type of Test (Serology, Urine, DNA Probe) | Results | Medication Used and Amount | Date |\n|  |  |  |  |  |\n|  |  |  |  |  |\n\n* For Information on other Notifiable Conditions or Disease Reporting, please call (800) 821-5821  \n* For Complete Rules For The Control Of Notifiable Conditions, please visit:  \n[http://www.maine.gov/dhhs/mecdc/infectious-disease/epi/disease-reporting/index.shtml](http://www.maine.gov/dhhs/mecdc/infectious-disease/epi/disease-reporting/index.shtml)","cbCaiqEHBTX0RjCy","https://ap.wps.com/l/cbCaiqEHBTX0RjCy","pdf",31671,"English","# Patient Information\n## Partner Information\n# Reporting and Clinical Details\n# Laboratory and Treatment Records","[{\"question\":\"What key information is collected for the patient in this STD case report?\",\"answer\":\"The form collects patient name/phone/address, report date, date of birth, sex, race and ethnicity, marital status, pregnancy status, and reason for exam, plus disease type and syphilis stage when applicable.\"},{\"question\":\"How does the form document testing and treatment?\",\"answer\":\"It records lab name and lab phone, test dates, test type (serology, urine, DNA probe), results, and medication used with amount, along with whether the patient was treated for infection(s).\"},{\"question\":\"What partner information is included and how is it used?\",\"answer\":\"If known, it captures partner name, phone, DOB, address, race and ethnicity, whether the partner was tested and treated, and the partner’s lab test details including results and medication.\"}]","STD Case Report - Sexually Transmitted Disease Case Report | PDF",1790060028]