General ID

Fuchia ID

Plz put number

Age

Gender

First Visit

If Last Visit

Heard about clinic

Registration/Follow-Up Date

Plz put number

STI diagnosis

Episode

Reasons For Visit

Risk Factor_Male

Risk Factor_Female

Test For Male

Urethral discharge

How long days

Plz put number

Scrotal Swelling

How Long

Tender/ Non-Tender

Test For female

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

Test For Any Sex

Dysuria

How long

Plz put number

Genital Prutitus

How long

Plz put number

Genital burnig or Pain

How Long

Plz put number

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

Genital Warts

How Long

Physical Exam

Test For Female

Washed inside < 1 hour

Vulvar erythema

Vulvar odema

Vaginal Discharge

Amount

Homogeneous

Colour

Smell(Without KOH)

Location

Vaginal wall injury

Adnexal tenderness

Adnexal enlargement

Genital blisters

Location

KOH smell test

pH Vagina

Make drawing and describe

Test For Male

Urinated within < 1 hour before visit

Discharge

Discharge after milking

Colour

Erythema on glans

Blisters on Penis

Estimated Size

Scrotal swelling

Estimated Size

Unilateal/Bilateral

Tender/Non-Tender

Erythema

Make Drawing and describe size

Test For Any Sex

Genital ulcer

Signle/Multiple

Painfull/Painless

Herpes suspected

Inguinal bubo

Fluctant

Tender/non tender

Other Leg infection

Genital Warts

Crab lice

Scabies

Test for Female

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)

Test for male

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

Patient's First Visit To Clinic

Patient's 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
Secondary Syphillis
Chancroid
Genital Herpes
Genital Scabies
Others

Gonorrhoea
Non-Gonococcal Urethritis
Non-Gonococal proctitis
Trichomonas
Gential Candidiosis
Baterial Vaginosis

Congenial Syphillis
Latent Syphillis
Non-Gonococal Cervities
Latent Syphillis (pregnancy)
Molluscum Contagiosum
Bubos
Genital Warts
Others

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)

STI follow up History

Serial No.	Clinic Code	Gender	Age	Risk Factor	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

STI Entry

STI diagnosis

Test For Male

Test For female

Test For Any Sex

Test For Female

Test For Male

Test For Any Sex

Test for Female

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

Test for male

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

Treatment (Fill in dose)

STI follow up History

RPR Test History

Search Data in STI Register and Update

Do a risk assement for Cervical infection

(*Spontaneous expressed complaints Only)
fof HR
women of irregular visit( Last Visit > 3 mths ago).

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