STI CLINIC VISIT Female_final draft1
Reason for visit [select name="variable_1" value="Patient has partner treated for a sexually transmitted infection.|Patient requesting STI testing|Patient received positive STI testing results and is here for treatment."] CC: [text size="50"] HPI:[text size="3"] yo FEMALE presents for [select name="reason" value="TESTING|TESTING AND TREATMENT|TREATMENT"] of [select name="ty" value="STIs|CHLAMYDIA|GONORRHEA|SYPHILIS|CHLAMYDIA AND GONORRHEA|CHLAMYDIA,GONORRHEA, and SYPHILIS"]. Pt labs [textarea name="labdate" default="date"] positive for [textarea name="swab" default="UROGENITAL RECTAL PHARYGEAL CHLAMYDIA AND UROGENITAL RECTAL PHARYGEAL GONORRHEA.RPR NON REACTIVE. REACTIVE. REACTIVE at _:_. Previous RPR _:_."]. Patient is [select name="SYMPT" value="ASYMPTOMATIC|SYMPTOMATIC"]. Patient symptoms history: [checklist name=""Symptoms" value="Increased vaginal discharge|Lower abdominal pain/Pain with intercourse|Pain/burning on urination|Increase in urinary frequency or urgency|Abnormal bleeding (vaginal, menses, post-coital)|Right Upper Quadrant pain|Nausea and or vomiting|Fever and/or chills|Sore throat and/or hoarseness|Rash or lesion|Asymmetric, painful, swollen joints|Rectal discharge, itching,soreness, bleeding, or painful bowel movements"] -Symptoms started [text size="3"] [select value="day(s)|week(s)|hour(s)|month(s)|year(s)"] ago.[text size="80"]. -Related activities or events that occured at or right before symptoms started: [text size="80"]. Was partner treated? [textarea name="partner" default="sample text"] Are you pregnant?[select name="pregnant" value="NA|No|Yes"] Are you breastfeeding?[select name="breastfeeding" value="NA|No|Yes"] Antibiotics in last 4 weeks?[select name="Antibioticsinlast4weeks" value="No|Yes"] Pt is calm, cooperative, and agreeable to treatment today. Avoid alcohol and sexual activity for 7-10 days after treatment. Patient was encouraged to notify partner(s). Safer sex practices discussed and encouraged. Condoms offered. Patient was given an opportunity to ask questions and all questions were answered. Patient verbalized understanding of all information presented.
There are 17 form elements.