STI ASSESSMENT FORM

EDUNURSIFY

🏥 STI/STD PATIENT ASSESSMENT FORM

Comprehensive Clinical Evaluation

📋 PATIENT PROFILE

Patient Name:
Medical Record Number:
Age:
Date of Birth:
Gender Identity:
Sex Assigned at Birth:
Contact Number:
Date of Assessment:
Address:

🔍 REASON FOR VISIT/HOSPITALIZATION

Chief Complaint:
Type of Visit:	Outpatient Emergency Inpatient Screening Contact Tracing

📝 HISTORY OF PRESENT ILLNESS

Onset of Symptoms:
Detailed Description:
Common STI Symptoms:	Discharge Dysuria Ulcers Warts Pain Itching Bleeding Rash Swollen Nodes Fever Asymptomatic
Previous Treatment:
Partner Symptoms:

🏥 PAST MEDICAL HISTORY

Previous STI History:
Chronic Medical Conditions:
Current Medications:
Drug Allergies:
Past Surgical History:
Gynecological/Urological Procedures:
Immunization Status:	HPV Vaccine Hepatitis B Hepatitis A

👤 PERSONAL HISTORY

Smoking Status:
Alcohol Consumption:
Recreational Drug Use:
Occupation:
Living Situation:
Travel History (12 months):

👨‍👩‍👧‍👦 FAMILY HISTORY

Relevant Family History:
Genetic Conditions:

❤️ SEXUAL HISTORY (CONFIDENTIAL)

🔒 Confidential Information: Ensure privacy and use non-judgmental language.

Sexual Orientation:
Age of Sexual Debut:
Lifetime Partners:
Partners (Past 3 months):
Partners (Past 12 months):
Gender of Partners:	Males Females Transgender Non-binary
Types of Sexual Activity:	Vaginal Anal (Receptive) Anal (Insertive) Oral (Giving) Oral (Receiving)
Condom/Barrier Use:
Date of Last Sexual Contact:
Date of Last Unprotected Sex:
Relationship Status:
Partner's STI Status:
Commercial Sex Work:	Yes No
History of Sexual Assault:
PrEP Use:	Current Previous Never
Last STI Screening:

🩸 MENSTRUAL HISTORY (For Females)

Age at Menarche:
Last Menstrual Period:
Cycle Length:
Duration of Menses:
Menstrual Abnormalities:	Amenorrhea Heavy Bleeding Intermenstrual Post-coital Painful
Menopausal Status:

🤰 OBSTETRIC HISTORY (For Females)

Gravidity:
Parity:
Pregnancy Outcomes:
Pregnancy Complications:
Currently Pregnant:	Yes No Unknown
Contraception Method:
Breastfeeding Status:
Last Pap Smear:
Cervical Screening Results:

💼 SOCIOECONOMIC HISTORY

Educational Level:
Employment Status:
Marital Status:
Insurance/Healthcare Coverage:
Access to Healthcare:
Social Support System:
Housing Stability:

📌 OTHER RELEVANT HISTORY

Mental Health History:
History of Incarceration:
Blood Transfusion History:
Tattoos/Piercings:
Cultural/Religious Considerations:
Reason for Testing Today:	Symptomatic Partner Notification Routine Screening High-Risk Prenatal Post-Assault
Additional Notes:

🔬 PHYSICAL EXAMINATION

Guidelines: Ensure privacy, maintain dignity, use chaperone when appropriate.

General Appearance:
Temperature:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Skin Examination:
Lymph Nodes:
Oral/Pharyngeal:
Abdominal Examination:

Genital Examination - Males

Penis:
Urethral Meatus:
Scrotum:
Testes/Epididymis:

Genital Examination - Females

External Genitalia:
Vaginal Examination:
Cervix:
Bimanual Examination:
Bartholin/Skene Glands:

Anorectal Examination

Perianal Area:
Digital Rectal Exam:

🧪 DIAGNOSTIC INVESTIGATIONS

Window Periods: HIV 4th gen: 45 days; Syphilis: 6-12 weeks

Serology

Tests Ordered:

HIV Ag/Ab Syphilis Hepatitis B Hepatitis C HSV-1/2

NAAT Tests

Tests Ordered:

CT/GC Genital CT/GC Rectal CT/GC Pharyngeal Trichomonas Mycoplasma HSV PCR

Other Tests

Tests Ordered:	Pregnancy Test Pap Smear Wet Mount Gram Stain Culture Ultrasound
Additional Tests:

🩺 ASSESSMENT & DIAGNOSIS

Primary Diagnosis:
Differential Diagnoses:
Risk Stratification:	Low Risk Moderate Risk High Risk

💊 MANAGEMENT PLAN

Immediate Treatment

Treatment Given:

Counseling Provided

Topics Discussed:

Safe Sex Abstinence Partner Treatment Medication Compliance Risk Reduction PrEP/PEP Vaccination

Follow-Up Plan

Follow-Up Date:
Test of Cure:	Yes No
Repeat Testing Schedule:
Referrals Made:

Partner Management

Notification Method:	Patient Notify Provider Notify EPT Declined
Partners to Notify:

📝 CONSENT & DOCUMENTATION

Informed Consent:	Examination Testing HIV Test Treatment Contact Tracing
Confidentiality Discussed:	Yes
Reporting Requirements:

👨‍⚕️ CLINICIAN INFORMATION

Clinician Name:
Signature:
Date:
Time:
Facility/Clinic:

🔒 CONFIDENTIAL PATIENT HEALTH INFORMATION
Store securely in compliance with HIPAA and local privacy regulations