SGP_STI


1. Identification

GP code

Startdate of consultation week (monday)

Format: mm-dd-yyyy

Sex patient
Male
Female
X
Agegroup patient
< 15 year
15 - 29 year
30 - 44 year
45 - 59 year
60 - 74 year
>= 75 year
Which type of IDcard your patient possess?
Does the patient has access to OMNIO/BIM statute, urgent medical aid, CPAS/OCMW or other financial help?

2. Diagnostic

Diagnosis STI
  First infection Reinfection Not applicable
Chlamydia trachomatis
First infection
Reinfection
Not applicable
Gonorrhoea
First infection
Reinfection
Not applicable
Condylomata
First infection
Reinfection
Not applicable
Syphilis
First infection
Reinfection
Not applicable
Genital herpes
First infection
Reinfection
Not applicable
Is your patient HIV positive?

3. Consultation

Reason of consultation
STI symptom(s)
GP initiated screening
Patient initiated screening
STI infected partner
Other reason

4. Risk factors

Was patient born abroad?
Level of education patient
Primary education or less
Secondary education
Higher education
Unknown
Sexual orientation
Homosexual contacts
Heterosexual contacts
Bisexual contacts
Unknown
Number of sex partners within the last 6 months
< 3
>= 3
Unknown
Does the patient use condoms with non-stable/non-regular sexual partners?
Does the patient use Pre-exposure prophylaxis (PrEP)?
Is the patient vaccinated against HPV?
Did you discuss informing and treating the sexual partner(s)?