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Sexually Transmitted Infection Report Form Template

Streamline STI Reporting for Enhanced Patient Care

Creating a safe space for your patients to report STI symptoms can be challenging. This template is designed for healthcare providers looking to efficiently gather crucial information from patients regarding sexually transmitted infections, helping to facilitate accurate diagnoses and care plans. By utilizing this form, you can ensure confidentiality, enhance patient trust, and streamline the collection of vital health data, all while providing a WCAG-aligned experience for accessibility. Explore the live template to see how it can transform your reporting process.

Use this Template (FREE) Live Preview
Who is this report about?
Me
A patient/client
A minor
Other/unsure
Email
Phone number
Preferred contact method for follow-up
Email
Phone
Text message
Do not contact
Full name of the individual this report is about (if known)
Date of birth
Sex assigned at birth
Female
Male
Intersex
Unknown
Prefer not to say
City or ZIP/Postal code
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Which infection(s) are involved?
Date of specimen collection or test
Where was the test performed? (facility or location)
Test result status
Positive
Negative
Indeterminate
Pending
Not tested
Are you experiencing any symptoms currently?
Yes
No
Which symptoms apply?
Please Specify:
Approximate symptom onset date
In the last 60 days, how many sexual partners have you had?
0
1
2-3
4-5
6+
Do you know any partners who tested positive for an STI in the last 60 days?
Yes
No
Have you started treatment for this condition?
Yes
No
Treatment details and any relevant medication allergies (e.g., antibiotics, penicillin)
Do you consent to share required information with public health authorities, as permitted by law?
Yes
No
Do you consent to anonymous partner notification support?
Yes, I consent
No, I do not consent
Not applicable
Do you consent to be contacted for confidential follow-up if needed?
Yes
No
Signature (type your full name)
Signature date
I confirm the information provided is accurate to the best of my knowledge.
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration depicting a report form for sexually transmitted infections with design elements related to health.

When to use this form

Use this form to document and report confirmed or suspected STIs in clinics, labs, campus health, community testing, or telehealth. Capture patient demographics, exposure history, symptoms, test details, diagnosis, treatment, and follow-up. It helps you meet reporting timelines and coordinate partner services. Pair it with a Medical questionnaire form to record risk factors and history, and with a Medical examination report form to summarize findings for the chart. Use it after positive NAAT or serology, during post-exposure visits, or when public health requests a case report. The outcome: consistent records, faster contact tracing, and a clear handoff between your team, the lab, and public health.

Must Ask Sexually Transmitted Infection Report Questions

  1. What is the patient's full name, date of birth, and contact information?

    This identifies the case and prevents duplicate records. It also gives your team and public health a way to follow up for treatment and partner services.

  2. What symptoms are present, and when did they start?

    Onset dates create a clear timeline for exposure and infectious period. Symptom details help triage urgency and guide testing and treatment.

  3. Which lab tests were performed, including specimen type, collection date, and results?

    Listing the test, specimen, and dates links the lab proof to the case and supports state reporting. If you also document exam findings, you can attach an Adult physical exam form for a complete record.

  4. What is the confirmed or suspected infection, and what is the diagnosis date?

    Naming the condition and dating the diagnosis sets the reporting clock and directs partner notification steps. It also determines which results and treatments you must include.

  5. What treatment was given, and has partner notification or counseling been documented?

    Documenting drug, dose, and dates shows care quality and helps prevent reinfection. If the patient needs job clearance after treatment, include a Return to work form to support HR or school needs.

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