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Discipline

: General

Sub Discipline

: test

Document Title

: Dermatology Clerking Note - Sexually Transmitted Infections (STI)

HISTORY

Chief Complaints

Urethral discharge

Duration and Location

Vaginal discharge

Duration and Location

Genital Ulcer

Duration and Location

Growth/warts

Duration and Location

Others, specify

Duration and Location

History Of Present Complaint

Past Medical History

Nil

Diabetes Mellitus (DM)

Dyslipidaemia

Hypertension (HPT)

Ischaemic Heart Disease

Asthma

Tuberculosis (TB)

Chronic Obstructive Airway Disease(COAD)

Stroke

Epilepsy

Chronic Kidney Disease (CKD)

Atopic Eczema

Allergic Rhinitis

Hyperthyroidism

Hypothyroidism

Others, specify

Past Surgical History

Past Sti

Obstetric / Menstrual History

Drug History

Drug History

Allergies And Alert

Social History

Marital Status

Children

Occupation

Comments

Smoker

Alcohol Consumption

Other Relevant History (Shall Include High Risk Behaviour)

Family History

Risk Factors

Blood Transfusion

IVDU

Sexual relationship

Sexual History

Sexual Orientation

HeterosexualHomosexualBisexual

Number Of Partners

Relationship

Spouse

Regular

Sex worker

Casual

Others, specify

Last Sexual Encounter

General Condition and Examination

Vital Signs

General Description

Skin

Lymph Nodes

Eye

Buccal Mucosa

Genitalia

Anal/Rectal

Cardiovascular System

Respiratory System

Abdomen

Nervous System

Locomotor

Others, Specify

PROBLEM LIST

Problem List

DIAGNOSIS

Diagnosis

MANAGEMENT

Orders

Others, Specify

Treatment

Contact Tracing

Counseling

YesNo

By Who

Notification Done

YesNo

Referral

Outgoing Referrals

Plan

SIGNATURES

Notes Component

HISTORY
PROBLEM LIST
DIAGNOSIS
MANAGEMENT
SIGNATURES

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