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2012 WA DOH 347-102 - Benton-Frankliny

2012 WA DOH 347-102 - Benton-Frankliny-2026

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32 votes

The document is a confidential sexually transmitted disease (STD) case report form used by the Benton-Franklin Health District in Washington State. It includes sections for patient information, diagnosis of STDs such as gonorrhea, chlamydia, syphilis, and herpes, treatment regimens, and partner management plans. The form emphasizes the importance of reporting STDs within three workdays and provides guidelines for ensuring partner treatment and notification. Additionally, it outlines recommended antimicrobial regimens for various STDs and includes a fax prescription section for expedited partner therapy.

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Click ‘Get Form’ to open the 2012 WA DOH 347-102 - Benton-Frankliny 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, and ZIP code.
Provide the date of diagnosis and select the ethnicity and race options that apply. Ensure you check the appropriate reason for examination.
In the 'Diagnosis – Disease' section, indicate if Gonorrhea or Chlamydia is lab confirmed by checking the relevant box. Fill in any symptoms and treatment prescribed.
Complete the 'Partner Management Plan' by selecting a method for ensuring partner treatment. Indicate how many partners will be treated.
Finally, fill out the 'Reporting Clinic Information' with details about the diagnosing clinician and facility. Ensure all information is accurate before submission.

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Versions	Form popularity	Fillable & printable
2019	4.9 Satisfied (45 Votes)
2016	4.8 Satisfied (207 Votes)
2012	4 Satisfied (32 Votes)

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