Massachusetts Department of Public Health
Bureau of Infectious Disease and Laboratory Sciences
305 South Street, Jamaica Plain, MA 02130
Phone: 617-983-6801 Confidential Fax: 617-983-6813
To request Partner Notification Services for your patient, please call the Division of STD Prevention at (617) 983-6940
GONORRHEA
For assistance filling out this form, call (617) 983-6801
SUPPLEMENTAL CASE REPORT
Version 5/16/2018
PATIENT INFORMATION
Last First Med Rec #:______________________
Name:___________________________________Name:__________________________________DOB:___/____/___ Social Security #:_________________
Street Address:
Gender:
Homeless
Incarcerated
Male Female Transgender Unknown
City: Zip:
Ethnicity:
Hispanic/Latino Non-Hispanic Latino Unknown
White
Black
Asian
Native Hawaiian/Pacific Islander American Indian/Alaskan Native
Other(specify):__________________________ UnknownEnglish Other(specify):____________
Did the case have any symptoms?
Yes No
Unknown
Yes No Unknown Not applicable
If symptomatic, what was the patient diagnosed with? (check all that apply):
Males: Females:
If asymptomatic, why was the patient tested? (check all that apply):
Urethritis
Epididymitis
Proctitis
Pharyngitis
DGI
Other(specify):_____________
Cervicitis
PID
Proctitis
Pharyngitis
DGI
Other(specify):_______________
Reported contact to gonococcal case
Screening
Rescreening after previous positive
Patient request
Other(specify):_____________________________________________
Does the patient have sex with:
Has the patient exchanged money for sex and/or drugs?
Has the patient had sex while intoxicated and/or high?
Has the patient travelled out of the state in the last two months?
Has the patient been incarcerated in the last six months?
Other risk factors:_____________________________________________________________________________________________
Treatment Date:__ /___/___
Ceftriaxone 250 mg IM AND azithromycin 1 g PO Ceftriaxone 250 mg IM Other (specify):_______________________________________
TESTING AGENCY INFORMATION
Provider Name:__________________________________ Facility:________________________________________ Phone #:_________________________
Address:_____________________________________ City:_____________________ Zip:_______________ Fax:__________________
Testing Setting:
Drug Treatment Facility
HIV Counseling, Testing, and Referral Site
Blood Bank
TREATING CLINICIAN INFORMATION (If different from testing agency):
Clinician Name:______________________________ Facility:______________________________________________ Phone #:______________________
Address:____________________________________ City:____________________________________ Zip:______________ Fax:_________________
Clinician Practice Setting:
Private Practice or HMO
Community Health Center
ADMINISTRATIVE INFORMATION Date Form Completed: _____/______/______
Name/Contact Information of person completing report (if not treating clinician):____________________________________________________________
Hospital-based Clinic
STD, HIV, or Family Planning Clinic
ER or Urgent Care
School-based Clinic including College/University
Military/VA/Job Corps Clinic
Correctional Institution
Other(specify):__________________
Mental Health Services Site
Other(specify):______________________________________________________________________________
Private Practice or HMO
Community Health Center
Hospital-based Clinic
STD, HIV or Family Planning Clinic
ER or Urgent Care
School-based Clinic including College/University
Military/VA/Job Corps Clinic
Correctional Institution
Pregnant?
Unknown
Unknown
Unknown
Unknown
Unknown
Men Women Both
Yes No
Yes No
Yes (specify):________________________________ No
Yes No
Cell Phone #: Home Phone #:
Primary Language Spoken:
CLINICAL INFORMATION
Diagnosis Date:______/_______/_______
Race: (check all that apply)
Same as testing agency
Same as treating clinician
