Ion ) ZIP CODE SEX Male YR RACE – Check all that apply Hispanic Non-Hispanic Unknown DATE OF BIRTH MO DAY GENDER OF SEX PARTNERS Female White Asian Unknown Black Other American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander Male Female Both Unknown DIAGNOSIS – DISEASE GONORRHEA (lab confirmed) DIAGNOSIS - a only one SITE(S) - a all that apply Asymptomatic Symptomatic-Uncomplicated Pelvic Inflammatory Disease Ophthalmia Disseminated Other Complications: __________ D.
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How to fill out the WA DOH 347-102 - Cowlitz County online
Filling out the WA DOH 347-102 form online can be a straightforward process when you follow the right steps. This guide is designed to support users in accurately completing the Confidential Sexually Transmitted Disease Case Report, ensuring that all necessary information is provided without confusion.
Follow the steps to successfully complete the form online.
- Click ‘Get Form’ button to access the form and open it in the editor.
- Begin by entering the patient information. Fill out the last name, first name, middle initial, address, telephone number, city or town, state, and zip code. Ensure the date of birth, date of diagnosis, gender, and ethnicity are accurately recorded.
- Select the reason for the examination by checking the appropriate box: symptomatic, routine exam with no symptoms, or exposed to infection.
- Provide details regarding the diagnosis of sexually transmitted diseases. Indicate the specific disease by checking the applicable box (e.g., gonorrhea, chlamydia, syphilis). Include testing dates and any prescribed treatments.
- Complete the partner management plan by selecting the preferred method for ensuring partner treatment and indicating the number of partners to be treated.
- Fill in the reporting clinic information, including the date, diagnosing clinician, facility name, person completing the form, and their contact details such as address, telephone, city, state, and email.
- Review all provided information for accuracy and completeness. Make sure all fields are properly filled out before submitting.
- Once all fields are completed and reviewed, save your changes. You may then download, print, or share the form as needed.
Complete your documents online swiftly and accurately to ensure efficient reporting.
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Dec 14, 2022 — DOH 347-102, updated 12/14/2022. For persons with disabiliƟes, this...
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