CATCH Clinic Form—DERC
1) Name:
2) DOB: ____/____/________
4) Race/Ethnicity:
African American
5) Baltimore City Resident:
Y
Caucasian
N
7) Currently have health insurance:
Hispanic
3) Date of Visit: ____/____/________
Asian/Pacific Islander
6) Been incarcerated/detained:
Y
Y
N
Other:
If yes, when:____/____/________
N (If no, refer pt to case mgr for insurance initiation)
General Health
8) Current Medical Problems:
9) Current Medications:
10) Medication/Latex Allergies:
11) Regular Doctor/Clinic:
12) Received medical care in the past year in the following settings (check all that apply):
ER
Your Doctor
13) Results:
Public Health Clinic
Negative for STI
SBHC
Positive for:
GC
No Medical Care
In Detention/Placement facility
Other:
CT Positive Test Date: ____ / ____ / _______ Entered in Log:
Y
Sexual History
14) Ever had sex:
Y
N
15) Age at first intercourse:
16) Ever gotten someone pregnant:
18) Sex in the last 3 months:
Y
Y
N
17) Any children:
Y
N
If Yes, how many?
N
19) In the last 3 months had sex (check all that apply):
20) Date of last sex:
Orally
Anally
Vaginally
21) Age of current partner:
22) Number of lifetime partners: Male
Female
24) Sexual risk factors (check all that apply):
Sex while intoxicated/high
23) Number of partners in past 3 months: Male
>1 sex partner within one week
Sex with someone met online
Sex with an HIV + or Hep C+ person
Ever used IV drugs
Female
Sex with no condom
Sex in exchange for drugs or money
Ever had a partner who used drugs with needles
Other:
25) Condom use with last sex:
26) Partner contraception:
Y
Don’t know
27) Past STI (check all that apply):
Hep B
Hep C
N
GC
Other:
OCP’s
CT
Patch
Trich
Depo Provera
Syphilis
Implanon
HIV
IUD
HSV
Ring
Other:
Genital Warts/HPV
N
28) Last STI and date: (STI name)
(date) ____ /____/_________
29) Currently having any of the following symptoms (check all that apply):
Dysuria
Fever
Scrotal/Genital pain
Weight loss
Urinary frequency
Sores/lumps/bumps in genital area
Discharge from penis
Other:
Overall
(space for notes):
Overall Assessment/Plan
Assessment:
30) Patient has CT, treated with:
Azithromycin 1g PO x 1 now
Verbal order from
Other:
on (date) ____ /____/_______ at (time)
Medication administered on (date)___/___/_____ at (time) ____:_____ Initials of Provider:
____________________________________________________________________________________________________________
31) Patient has GC, treated with: Ceftriaxone 125mg IM x 1 now
Cefixime 400mg PO x 1 now
Ceftriaxone 250mg IM x 1 now
Verbal order from
Other:
on (date) ____/____/________at (time)
Medication administered on (date) ____/____/________ at (time) ____:_____
Initials of Provider:
32) Written handout provided and reviewed on Medication Information:
Y
N
N/A
33) Written handout with patient information on STI provided and reviewed:
Y
N
N/A
34) Discussed need for partner treatment :
Partner referral card given:
35) Goody bag provided:
Y
Y
36) Referred for Health Care to:
Y
N
N/A
N/A
N
On-site physician
37) Referred to outside Health Care Provider for:
General Healthcare
N
Other:
38) Appropriate counseling provided regarding:
off-site health care provider
Family Planning Services
N/A
Additional STI evaluation/treatment
N/A
STI avoidance
39) Report of positive GC/CT faxed to Baltimore City Health Dept:
Pregnancy prevention
Y
N
N/A
Condom use
Other:
Date sent: ____/____/________
Signature of Provider:
Date:
Signature of Physician:
Date:
CATCH Clinic Form—FIT
1) Name:
2) DOB: ____ /____/________
4) Race/Ethnicity:
African American
5) Baltimore City Resident:
Y
Caucasian
N
7) Currently have health insurance:
Hispanic
3) Date of Visit: ____ /____/________
Asian/Pacific Islander
6) Been incarcerated/detained:
Y
Y
N
Other:
If yes, when:____ /____/________
N (If no, refer pt to case mgr for insurance initiation)
General Health
8) Current Medical Problems:
9) Current Medications:
10) Medication/Latex Allergies:
11) Regular Doctor/Clinic:
12) Received medical care in the past year in the following settings (check all that apply):
ER
Your Doctor
13) Results:
Public Health Clinic
Negative for STI
SBHC
Positive for:
GC
No Medical Care
In Detention/Placement facility
Other:
CT Positive Test Date: ____ /____/______Entered in Log:
Y
N
Sexual History
14) Date of last menstrual period:
15) Pregnancy history: G
16) Ever had sex:
17) Age at first intercourse:
Y
N
18) Sex in the last 3 months:
Y
20) Date of last sex:
Orally
Female
24) Sexual risk factors (check all that apply):
Sex while intoxicated/high
Anally
Vaginally
23) Number of partners in past 3 months: Male
>1 sex partner within one week
Sex with someone met online
Sex with a man who has male partners
Sex with no condom
Sex in exchange for drugs or money
Ever had a partner who used drugs with needles
Y
Female
Sex with an HIV + or Hep C+ person
Other:
N
26) Current contraception other than condoms:
27) Past STI (check all that apply):
SAB
21) Age of current partner:
22) Number of lifetime partners: Male
25) Condom use with last sex:
TAB
N
19) In the last 3 months had sex (check all that apply):
Ever used IV drugs
P
GC
Genital Warts/Abnormal Pap/HPV
None
CT
Hep B
OCP’s
Trich
Hep C
Patch
Depo Provera
Syphilis
Other:
HIV
Implanon
HSV
IUD
BV
Ring
Other:
28) Last STI and date: (STI name)
(date) ____ /____/______
29) Currently having any of the following symptoms (check all that apply):
Vaginal itching
Fever
Sores/bumps/lumps in vaginal area
Weight loss
Unusual vaginal discharge
Dysuria
Abnormal/Irregular menses
Urinary frequency
Vaginal odor
Abdominal or pelvic pain
Other:
Overall Assessment/Plan (space for notes):
30) Patient has CT, treated with:
Azithromycin 1g PO x 1 now
Other:
Verbal order (if applicable) from_______________________ on (date): ____ /____/______ at (time):
Medication administered on (date)___/___/_____ at (time) ____:_____ Initials of Provider:
31) Patient has GC, treated with:
Ceftriaxone 125mg IM x 1 now
Cefixime 400mg PO x 1 now
Ceftriaxone 250mg IM x 1 now
Other:
Verbal order (if applicable) from_______________________on (date) ____ /____/______ at (time):
Medication administered on (date) ___/___/_____ at (time) ____:_____ Initials of Provider:
32) Written handout provided and reviewed on Medication Information:
Y
33) Written handout with patient information on STI provided and reviewed:
34) Discussed need for partner treatment
Y
N
N/A
N
Y
N/A
N
N/A
35) Partner referral card given
Y
Partner Prescription provided for:
Cefixime 400mg PO x 1 now
Azithromycin 1g PO x 1 now
Name of Partner receiving prescription:_________________________________________________
35) Urine Pregnancy Test Performed:
Y
N
Result:
Pos.
N
N/A
Other:
Neg.
36) Emergency Contraception (EC) offered if last unprotected sex within 5 days:
Y
N
Advanced provision
Y
N
Youth not interested in EC at this time
Verbal order (if applicable) from ___________________on (date)____/_____/_______at (time)___________
Levonorgesterel 0.75 mg x 2 tabs administered on (date)____/____/_______ at (time)________ Provider initials__________
Written handout on EC given and reviewed
Y
N
N/A
37) Consent form reviewed and signed?
39) Referred for Health Care:
Y
Y
38) Goody bag provided:
Y
N
N
40) Referred to outside Health Care Provider for:
Additional STI evaluation/treatment
N
Pregnancy
Family Planning Services
General Healthcare
41) Appropriate counseling provided regarding:
Other:
STI avoidance
42) Report of positive GC/CT faxed to Baltimore City Health Dept:
N/A
Pregnancy prevention
Y
N
N/A
Condom use
Other:
Date sent: ___/____/________
Signature of Provider (if other than physician):
Date:
Signature of Physician:
Date: