Fillable STD CONFIDENTIAL MORBIDITY REPORT (HSA)

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STD CONFIDENTIAL MORBIDITY REPORT (HSA)

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The STD CONFIDENTIAL MORBIDITY REPORT (HSA) form is 1 page long and contains:

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  • 65 check-boxes
  • 77 other fields

Country of origin: US
File type: PDF

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STD CONFIDENTIAL MORBIDITY REPORT
DISEASE:
CHLAMYDIA
GONORRHEA
SYPHILIS/Stage:
Patient’s Last Name
First Name/Middle Name (or Initial)
Social Security Number
Birth Date Age
MM
DD
YY
Years
Ethnicity ( one)
Hispanic/Latino
Non-Hispanic/Non-Latino
Race ( one)
African-American/Black
Asian/Pacific Islander ( one)
Asian-Indian
Cambodian
Chinese
Filipino
Guamanian
Hawaiian
Native American
Caucasian/White
Other:
Japanese
Korean
Laotian
Samoan
Vietnamese
Other:
Address: (Number, Street)
City/Town State Zip Code
Area Code Home Telephone Gender
M
F
M to F
F to M
Other:
Language Spoken:
Area Code Work Telephone Pregnant? Est. Delivery Date
Y
N
UNK
MM
DD
YY
Area Code Cell Telephone Email
Reporting Health Care Provider
REPORT TO
COUNTY OF SANTA CRUZ
Health Services Agency
1060 Emeline Ave
Santa Cruz, CA 95060
Phone: (831) 454-4114
Fax: (831) 454-5049
DATE OF ONSET
Month
Day
Year
Reporting Health Care Facility
Address
DATE DIAGNOSED
Month
Day
Year
City State Zip Code
Telephone:
Fax:
SPECIMEN COLLECTED
Not tested
Submitted by:
Submit Date:
Month
Day
Year
STD DIAGNOSIS
Syphilis
Primary (lesion present)
Secondary
Early latent < 1 year
Neurosyphilis
Late Latent > 1 year
Late (tertiary)
Congenital
Syphilis Test Results
RPR Titer:
VDRL Titer:
FTA/TPPA: Pos Neg
CSF-VDR: Pos Neg
Other
Gonorrhea
Urine
Urethral/Cervical
PID/Gonorrhea
Rectal
Pharyngeal
Chlamydia
Urine
Urethral/Cervical
PID/Chlamydia
Rectal
PID
Chancroid
STD TREATMENT INFORMATION
PARTNER INFORMATION
Treated:
Drugs:
Partner’s Name Age
Treated in office w/:
Given prescription for:
Dosage:
Address City
State
Zip
Treated Presumptively
Date Treatment Given:
Home Phone Work Phone
Will treat
Untreated
Treated:
Drugs:
Unable to contact patient
Treated in office w/:
Given prescription for:
Dosage:
GENDER OF SEX PARTNERS: (check all that apply)
Patient delivered partner tx:
Male
Female
Unknown
Male to Female Transgender
Female to Male Transgender
Other:
Will Treat
Date Treatments Given:
Untreated
NOTES:
Rev 2018
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STD CONFIDENTIAL MORBIDITY REPORT (HSA)

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Completed 21 February 2021

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