Massachusetts Department of Public Health
Bureau of Infectious Disease and Laboratory Sciences
Office of Integrated Surveillance and Informatics Services
305 South Street, Jamaica Plain, MA 02130
Phone: 617-983-6801 Confidential Fax: 617-983-6813
To request Partner Notification Services for your patient, please call the Division of STD Prevention at (617) 983-6940
SYPHILIS
For assistance filling out this form, call (617) 983-6801
CASE REPORT FORM
Version 5/16/2018
PATIENT INFORMATION
Last First DOB:___/____/___ Med Rec #:______________________
Name:___________________________________Name:_________________________________Middle Initial:______Social Security #:_________________
Street Address:
Gender:
Homeless
Incarcerated
Male Female Transgender Unknown
City: Zip:
Ethnicity:
Hispanic/Latino Non-Hispanic Latino Unknown
White
Black
Asian
Native Hawaiian/Pacific Islander American Indian/Alaskan Native
Other(specify):__________________________ UnknownEnglish Other(specify):____________
Did the patient have any symptoms?
Yes No
Unknown
Yes No Unknown Not applicable
If symptomatic, what stage of syphilis was
patient diagnosed at? (check all that apply):
If asymptomatic, why was the patient tested?
(check all that apply):
Primary syphilis
Secondary syphilis
Neurosyphilis
Other(specify):
Early latent syphilis (infection acquired<1 yr ago)
Late latent syphilis (infection acquired>=1 yr ago)
Latent syphilis of unknown duration
Other(specify):
Reported contact to syphilis case
Screening
Rescreening after previous positive
Patient request
Other(specify)
Other treatment (specify:) _______________________________________
Does the patient have sex with:
Has the patient exchanged money for sex and/or drugs?
Has the patient had sex while intoxicated and/or high?
Has the patient travelled out of the state in the last year?
Has the patient been incarcerated in the last six months?
Other risk factors:_____________________________________________________________________________________________
Benzathine penicillin G 2.4 million units IM--
1 dose (for primary, secondary,
early latent syphilis)
Benzathine penicillin G 2.4 million units IM -
3 doses, 1week apart (for late latent,
or latent syphilis of unknown duration)
Aqeuous crystalline penicillin G 3-4 million
units IV every 4 hours or continuous infusion
for 10-14 days (for neurosyphilis)
TESTING AGENCY INFORMATION
Provider Name:__________________________________ Facility:________________________________________ Phone #:_________________________
Address:_____________________________________ City:_____________________ Zip:_______________ Fax:__________________
Testing Setting:
Drug Treatment Facility
HIV Counseling, Testing, and Referral Site
Blood Bank
TREATING CLINICIAN INFORMATION (If different from testing agency):
Clinician Name:______________________________ Facility:______________________________________________ Phone #:______________________
Address:____________________________________ City:____________________________________ Zip:______________ Fax:_________________
Clinician Practice Setting:
Private Practice or HMO
Community Health Center
ADMINISTRATIVE INFORMATION Date Form Completed: _____/______/______
Name/Contact Information of person completing report (if not treating clinician):____________________________________________________________
Hospital-based Clinic
STD, HIV, or Family Planning Clinic
ER or Urgent Care
School-based Clinic including College/University
Military/VA/Job Corps Clinic
Correctional Institution
Other(specify):__________________
Mental Health Services Site
Other(specify):
Private Practice or HMO
Community Health Center
Hospital-based Clinic
STD, HIV or Family Planning Clinic
ER or Urgent Care
School-based Clinic including College/University
Military/VA/Job Corps Clinic
Correctional Institution
Pregnant?
Unknown
Unknown
Unknown
Unknown
Unknown
Men Women Both
Yes No
Yes No
Yes (specify):________________________________ No
Yes
Not treated
No
Cell Phone #: Home Phone #:
Primary Language Spoken:
CLINICAL INFORMATION
Diagnosis Date:______/_______/_______
Race: (check all that apply)
Same as testing agency
Same as treating clinician
If asymptomatic, what stage of syphilis was patient
diagnosed at? (check all that apply):
Treatment Date: ______ /______ / ______
