ࡱ> q   bjbjt+t+ "AA]fb p8 \ $<D DD$ f$$$D  D$$ 24`WDATA IDENTIFIER  FORMTEXT      New Jersey Department of Health CONFIDENTIAL SEXUALLY TRANSMITTED DISEASE REPORTDATE OF REPORT  FORMTEXT      PATIENT NAME (Last, First, Middle/Maiden)  FORMTEXT      PHONE NUMBER  FORMTEXT      PATIENT STREET ADDRESS  FORMTEXT      AGE  FORMTEXT    DATE OF BIRTH  FORMTEXT      PREGNANT  FORMCHECKBOX  Yes  FORMCHECKBOX  NoSEX  FORMCHECKBOX  M  FORMCHECKBOX  FRACE  FORMCHECKBOX  White  FORMCHECKBOX  Black FORMCHECKBOX  Am. Indian  FORMCHECKBOX  Asian/Pac.Is.  FORMCHECKBOX  OtherETHNICITY  FORMCHECKBOX  Hispanic  FORMCHECKBOX  Non-HispanicCITY/TOWN  FORMTEXT      ZIP CODE  FORMTEXT      STD DISEASE CODESPLEASE WRITE IN CODES FOR DISEASE(S) YOU ARE REPORTING FOR THIS PATIENT:710 Primary Syphilis (lesion present)100 Chancroid720 Secondary Syphilis (rash present)200 Chlamydia FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT    FORMTEXT   730 Early Latent Syphilis (<1 yr. duration)300 Gonorrhea *745 Late Latent Syphilis (>1 yr. or unknown duration)500 Granuloma Inguinale*Number of times this patient had a positive test for 300 (gonorrhea) at this site in the past 90 days?750 Late Syphilis with Symptomatic Manifestations600 Lymphogranuloma Venereum FORMTEXT   760 Neuro SyphilisPROVIDER/HOSPITAL/ PHYSICIAN: FORMTEXT      FOR NJDOH USE ONLYFIELD UNIT CASE #:  FORMTEXT      ADDRESS: FORMTEXT      CITY/STATE/ZIP: FORMTEXT      PROVIDER TYPE CODE #:  FORMTEXT       FORMTEXT       FORMTEXT      TELEPHONE: FORMTEXT       LABORATORY TESTTREATMENT ADMINISTEREDNAME OF LAB( FORMTEXT      Date Treatment Started( FORMTEXT      DateTestReactiveTiterNon-Reactive FORMCHECKBOX  Benzathine PCN, 2.4 mu IM x  FORMTEXT ____ weekly doses FORMTEXT      RPR FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Ceftriaxone (Rocephin), 250 mg IM  FORMTEXT      VDRL FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Doxycycline 100 mg p.o. bid x  FORMTEXT ____ days FORMTEXT      FTA-ABS FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Azithromycin 1 gm FORMTEXT      TP-PA FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Other:  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  NO TREATMENT ADMINISTERED FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      (Explain in Comments)PLEASE FAX REPORT TO THE STD PROGRAMDateDiseaseResultTest TypeSpecimen SiteAT: (609) 826-4870 FORMTEXT      CHLAMYDIA FORMTEXT       FORMTEXT       FORMTEXT      If unable to fax, see Contact Information below for  FORMTEXT      GONORRHEA FORMTEXT       FORMTEXT       FORMTEXT      mailing reports.COMMENTS:  FORMTEXT       FORMTEXT      STD-11 MAY 16 To find the STD-11, CONFIDENTIAL SEXUALLY TRANSMITTED DISEASE REPORT form, please go to:  HYPERLINK "http://www.nj.gov/health/std/" nj.gov/health/std/ CONTACT INFORMATION: New Jersey Department of Health Sexually Transmitted Disease Program PO Box 363 Trenton, NJ 08625-0363 PHONE: (609) 826-4869 46JLNXZ\246@BD^x  JL`ݜ݄tj\5CJOJQJUj5CJOJQJU6CJOJQJjt5CJOJQJU56CJOJQJ5CJOJQJj5CJOJQJUmHj5CJOJQJU5CJOJQJj5CJOJQJU CJOJQJ CJOJQJ)  4\Dt$$$$F$$TH84rly(&))$$TH84)$  4\DFHJLNPRTVXZ\^Jrtvxz|~:dl&` X l   d  bDFHJLNPRTVX \$$TH4֞l!q!y(&))```$ XZ\^Jrtv<$$$\$$TH4֞l!q!y(&)) `bdnpr,.0:<XZ\bln㾮㾞͌wi͌jCJOJQJUj,CJOJQJU CJOJQJjCJOJQJU CJOJQJj5CJOJQJUjD5CJOJQJU5CJOJQJ CJOJQJ CJOJQJj5CJOJQJUmHj5CJOJQJUj5CJOJQJU$vxz|~ $\$$TH4֞ly(&))  ```  :dl&H$H$$$$$\$$TH4֞ly(&))      $&(DFH`b~     8 ߼߮ߠߒ߄vj@CJOJQJUjCJOJQJUjXCJOJQJUjCJOJQJUjpCJOJQJUjCJOJQJU 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