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STD Case Report form - Jefferson County Public Health - jeffersoncountypublichealth 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling out the 'Patient Information' section. Enter the patient's last name, first name, middle initial, address, telephone number, city, state, zip code, date of birth, and ethnicity. Ensure all fields are completed accurately.
- In the 'Reason for Exam' section, check the appropriate box that describes why the patient is being examined: symptomatic, routine exam with no symptoms, or exposed to infection.
- Proceed to the 'Diagnosis' section. Select the disease diagnosed (e.g., Gonorrhea or Chlamydia) and indicate if it was lab confirmed. Fill in any relevant details regarding treatment prescribed and dates.
- Complete the 'Partner Management Plan' by selecting a method for ensuring partner treatment. This may include indicating how many partners will be treated and whether health department assistance is needed.
- Finally, fill out the 'Reporting Clinic Information' section with details about the diagnosing clinician and facility. Ensure all contact information is accurate for follow-up purposes.
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