General ID

Fuchia ID

Plz put number

Age

Gender

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Select Male or Female Form

First Visit

If Last Visit

Heard about clinic

Registration Date

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STI diagnosis

Episode

Reasons For Visit

Risk Factor

Urethral discharge

How long days

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Abnormal vaginal discharge

How Long

Linked with menstruation

Amount

Colour

Other(Specify)

Abnormal vaginal odour

Lower abdominal pain

How Long

Fever

Recent Termination Pregnancy

Dyspareunia

Other GI Symptoms

Dysuria

How long

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Genital Prutitus

How long

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Genital burnig or Pain

How Long

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Genital ulcer

How Long

Pain

Ulcer

Prodormal itch/buring

Started as vesicles /blisters

Recurrent

Last Episode

Patient Suspects Herpes

Inguinal lymph node

How Long

Unilateal/Bilateral

Leg ulcer/other infection

Scrotal Swelling

How Long

Tender/ Non-Tender

Genital Warts

How Long

Physical Exam

Urinated within < 1 hour before visit

Discharge

Discharge after milking

Colour

Washed inside < 1 hour

Vulvar erythema

Vulvar odema

Vaginal Discharge

Amount

Homogeneous

Colour

Smell(Without KOH)

Vaginal wall injury

Adnexal tenderness

Adnexal enlargement

Genital blisters

Location

Erythema on glans

Blisters on Penis

Genital ulcer

Location

Estimated Size

Signle/Multiple

Painfull/Painless

Herpes suspected

Inguinal bubo

Fluctant

Tender/non tender

Other Leg infection

Genital Warts

Crab lice

Scabies

KOH smell test

pH Vagina

Make drawing and describe

Scrotal swelling

Estimated Size

Unilateal/Bilateral

Tender/Non-Tender

Erythema

Make Drawing and describe size

Previous STI(compl or confirmed)(2)

New partner within past 3 months (2)

Patient compl.Dysuria or genital ulcer(3)

Partner compl.Genital symptoms (3)

Patient compl. Lower abdominal pain (1)

Sex worker

Score

Risk Group

Risk Remark

Do a risk assement for Cervical infection (* Spontaneous expressed complaints ONLY) fof HR women of irregular visit( Last Visit > 3 mths ago).

Abnormal yellow discharge (if only abnormal abundant discaarge)(2)

Pain during sexual untercourse (1)

Dysuria(1)

Unprotected sex with new clients (1)

Lower abdominal pain (1)

Partner discharge/ Ulcer (2)

Do risk assessment for sexual transmitted infection (only for MSM).

Patient's First Visit To Clinic

Patient had an episode of discharge since the last visit.

Patient had unproteced sex with new partner.

Patient genital sign/symptoms

If any of above questions answered "Yes" ,Risk assessment (+)

Presumptive Diagnosis

Genital Ulcer Disease(GUD)s	Genital Disharge Diseases(GDS)s	Other STDs
Primary Syphillis	Gonorrhoea	Congenial Syphillis
Secondary Syphillis	Non-Gonococcal Urethritis	Latent Syphillis
Chancroid	Non-Gonococal proctitis	Non-Gonococal Cervities	Latent Syphillis (pregnancy)	Molluscum Contagiosum
Genital Herpes	Trichomonas	Bubos
Genital Scabies	Gential Candidiosis	Genital Warts
Others	Baterial Vaginosis	Others

Treatment (Fill in dose)

1. Azythro

2. Cefixim

3. Ciprofloxacin

4. Tinidazole

5. Fluconazole

6. Doxycycline

7. Ceftriaxone

8. Benz Pen

9. Clotrimazole vaginal tab

9. No Treatment

10. No Treatment

Allergy

Sulfa

Parter Treatment Given

Condom given

Remark for Treatment

Follow Up

Clinician Name

STI follow up History

No.	Row-ID	Visit Date

RPR Test History

No.	Row-ID	Visit Date	RPR Result

Search Data in STI Register and Update

General ID

No.	Row-ID	Visit Date