MSTIC Study clinic data extract form: GUM
Our ref:
Patient’s clinic number
Date of questionnaire/clinic attendance
Was this the patient’s first attendance ever?
Was it a ‘new’ or follow-up attendance?
Gender (please circle)
Date of birth (dd/mm/yy)
/
/
Y / N
New / Follow-up
M / F
/
/
PCT of residence
(please look up using patient’s postcode)
PCT(s)
no
postcode
given
Patient’s GP surgery, address, postcode (or
GP’s name)
(Please check patient’s file, and top sheet. Please
copy even if patient has not given to consent to
contact their GP. We will not be contacting individual
patients’ GPs).
Ethnic Origin
(see top sheet or registration form)
Related to the patient’s attendance on the date in the shaded box, above:
Genital examination
What tests were done for the patient on this date?
What
diagnoses
were made
during this
episode of
care?
(please tick
all that apply)
Treatment as
a contact on
this date:
Y
Chlamydia test
Y
Gonorrhoea test
Y
Blood for syphilis
Y
Blood for HIV
Y
Other
Y
B1/B2/B5
gonorrhoea (complicated or uncomplicated)
Y
C4A/C4B/C4C chlamydial infection (complicated/uncomplicated)
Y
C4H
non-GC/NSU or treatment of mucopurulent cervicitis in females Y
C6A
trichomoniasis
Y
C10A
anogenital herpes simplex: first attack
Y
C10B
anogenital herpes simplex: recurrence
Y
C11A
anogenital warts: first attack
Y
C11B
anogenital warts: recurrence
Y
A1-A6
syphilis requiring treatment
Y
Complicated STI: Was patient diagnosed with:
Epididymitis
Y
Pelvic inflammatory disease (PID) Y
Newly diagnosed HIV: E1A New HIV diagnosis: asymptomatic
Y
E3A1AIDS: first presentation: new HIV diagnosis Y
E1B
Subsequent HIV presentation
Y
B4
epidemiological treatment of suspected gonorrhoea
Y
C4E
epidemiological treatment of suspected Chlamydia
Y
C4I
epidemiological treatment of suspected NSGI
Y
C7B
epidemiological treatment of trichomoniasis
Y
A9
epidemiological treatment of suspected syphilis
Y
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N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
If diagnosed with Gonorrhoea / Chlamydia (leave blank for patients without GC/CT)
At least one partner reported tested
At least one partner reported treated
If information is unknown, please leave the response blank.
Date the form was filled in: ____ __/ __ ____/
_
Y / N
Y / N