FIªA DE INVESTIGAÞIE EPIDEMIOLOGICÃ ªI DECLARARE A

CAZULUI NOU DE ITS

 
                         (SIFILIS, GONOREE, INFECÞIE CU CHLAMYDIA)
 
    DSP Judeþ ___________________ Nr. Fiºã ITS _______ din data de:
___/___/___
    Nr. Din fiºa unicã (conf. HG 587/2007 ºi Ord. MS nr. 1466/2008)
___________ din data de: ___/___/______
    CNP ___/___/___/___/___/___/___/___/___/___/___/___/___/
 ________________________________________________________________
______________
| DATE STRICT CONFIDENÞIALE (nu se introduc în baza de
date)                   |
|                                                                 
             |
| Unitatea sanitarã ______________________________ Nr. Fiºã
__________________ |
|                                                                 
             |
| NUME _______________________________ PRENUME
_______________________________ |
|                                                                 
             |
| ACT DE IDENTITATE (BI, CI, paºaport), seria ______ Nr.
_________             |
|                                                                 
             |
| Eliberat de
________________________________________________________________
|
|                                                                 
             |
| DOMICILIUL STABIL: judeþ ________ localitate ________ Str.
_________ Nr. ___ |
|                                                                 
             |
| Bl. ______ AP. ____ Sector
______                                            |
|                                                                 
             |
| DOMICILIUL ACTUAL: judeþ ________ localitate ________ Str.
_________ Nr. ___ |
|                                                                 
             |
| Bl. ______ AP. ____ Sector
______                                            |
|
_________________________________________________________________
_____________|
 
    MEDIU: U/R
    VÂRSTA: (la data înregistrãrii)
__________________________________________
    SEX: M/F pentru F: Gravidã DA/NU dacã DA, luna de sarcinã
________________
    ªCOLARIZARE: Fãrã ___ preºcolar ___ primar ___ gimnazial ___
liceal ______ postliceal ___ studii superioare ____
    OCUPAÞIE: fãrã ___ elev/student ___ angajat ____ ºomer ____
pensionar ____ militar ___ ºofer ___ personal privat de libertate _____
altele (se specificã) __________________________
    STAREA CIVILÃ: cãsãtorit ___ necãsãtorit ___ divorþat ___ vãduv
___ relaþie stabilã ___
    COMPORTAMENT SEXUAL: heterosexual ___ homosexual ___
parteneri sexuali multipli ___
    sex comercial: DA/NU, dacã DA, de când practicã ________
    consum de droguri ___ niciuna din acestea ___
    Diagnostic sifilis: primar ___ secundar ___ latent ___ latent recent
___ latent tardiv ___ terþiar ___ necunoscut ___ contact .....
 ________________________________________________________________
______________
| Examene de laborator efectuate pentru
sifilis                                |
|                                                                 
             |
| 1. Evidenþiere de T.p. în câmp         DA/NU  Rezultat _____
Data __/__/____ |
|    întunecat                                                    
             |
|                                                                 
             |
| 2. Evidenþierea T.p. prin              DA/NU  Rezultat _____
Data __/__/____ |
|    imunofluorescenþã                                            
             |
|                                                                 
             |
| 3. Serologie teste cardiolipinice:     DA/NU  Rezultat _____
Data __/__/____ |
|    VDRL,
RPR                                                               
  |
|                                                                 
             |
| 4. VDRL cantitativ                     DA/NU  Rezultat _____
Data __/__/____ |
|                                                                 
             |
| 5. Serologie teste treponemice         DA/NU  Rezultat _____
Data __/__/____ |
|    (TPHA, FTA-
abs)                                                           |
|                                                                 
             |
| 6. Serologie IgM antitreponemice       DA/NU  Rezultat _____
Data __/__/____ |
|                                                                 
             |
| 7. HIV - ELISA                         DA/NU  Rezultat _____
Data __/__/____ |
|
_________________________________________________________________
_____________|
 
    Diagnostic infecþie gonococicã:
___________________________________
    contact ......
 ________________________________________________________________
______________
| Examene de laborator efectuate pentru
gonoree:                               |
|                                                                 
             |
| 1. Frotiu                              DA/NU  Rezultat _____
Data __/__/____ |
|                                                                 
             |
| 2. Culturã                             DA/NU  Rezultat _____
Data __/__/____ |
|                                                                 
             |
| 3. Teste de amplificare genicã         DA/NU  Rezultat _____
Data __/__/____ |
|                                                                 
             |
| 3. Serologie teste cardiolipidice      DA/NU  Rezultat _____
Data __/__/____ |
|    VDRL,
RPR                                                               
  |
|                                                                 
             |
| 4. HIV - ELISA                         DA/NU  Rezultat _____
Data __/__/____ |
|
_________________________________________________________________
_____________|
 
    Diagnostic: Infecþie cu Chlamydia trachomatis: _____________
contact .....
 ________________________________________________________________
______________
| Examene de laborator efectuate pentru infecþia cu
Chlamydia:                 |
|                                                                 
             |
| 1. Culturã                             DA/NU  Rezultat _____
Data __/__/____ |
|                                                                 
             |
| 2. Imunoflourescenþã directã           DA/NU  Rezultat _____
Data __/__/____ |
|                                                                 
             |
| 3. ELISA                               DA/NU  Rezultat _____
Data __/__/____ |
|                                                                 
             |
| 4. Diagnostic molecular                DA/NU  Rezultat _____
Data __/__/____ |
|    (Hibridizare AND-ARN sau
PCR)                                             |
|                                                                 
             |
| 5. VDRL                                DA/NU  Rezultat _____
Data __/__/____ |
|                                                                 
             |
| 6. HIV - ELISA                         DA/NU  Rezultat _____
Data __/__/____ |
|
_________________________________________________________________
_____________|
 
    ALTE BOLI CU TRANSMITERE SEXUALÃ ASOCIATE
______________________
    ANTECEDENTE - ALTE BOLI CU POSIBILÃ TRANSMITERE
SEXUALÃ:
 
    HIV:                               DA __ NU __ Netestat
______
    Dacã este HIV pozitiv data la care a intrat în CNLAS:
___/___/_______
    Hepatitã viralã tip B              DA __ NU __ Netestat __
    Hepatitã viralã tip C              DA __ NU __ Netestat __
    Infecþie cu C. trachomatis         DA __ NU __ Netestat __
    Herpes genital                     DA __ NU __ Necunoscut ___
    Infecþie cu Mycoplasma/Ureaplasma  DA __ NU __ Netestat __
Necunoscut __
    Sifilis                            DA __ NU __ Netestat __
    Gonoree                            DA __ NU __ Netestat __
(necunoscut)
 
    Alte ITS
_____________________________________________________________
____
    LOCALITATEA INFECTÃRII: localitatea de domiciliu ___ altã
localitate (care) __________ altã þarã (care) ____________
    CALEA DE TRANSMITERE: heterosexualã ___ homosexualã ___
mamã-fãt ____ alta __________ necunoscutã ____
    DATA PROBABILÃ A RAPORTULUI INFECTANT:
___/___/______ necunoscut ____
    DATA APARIÞIEI PRIMELOR SEMNE DE BOALÃ
___/___/______ necunoscut ____
    DATA DEPISTÃRII (data primului consult medical) ___/___/____
    LOCUL DEPISTÃRII: serviciu D-V ____ cabinet M.F. ____ UPU
____ ginecologie ____ urologie ____ serviciu de planificare familialã ___
serviciu de B.I. ___ clinicã ptr. tineri ____ altele (care)
_________________
    MOD DE DEPISTARE ACTIV: certificat prenupþial ___ examen la
angajare ___ control periodic ___ control serologic gravidã ___ donare
de sânge ºi organe ___ investigaþie epidemiologicã ____ alte (care)
___________
    MOD DE DEPISTARE PASIV
___________________________________
    DATA CONFIRMÃRII (data rezultatului de laborator pozitiv)
___/___/______
    SURSA DE INFECTARE: depistatã DA ____ NU ____ testatã: DA
_____ NU _____
    Data testãrii sursei ____/____/______ Rezultat testare: pozitiv ____
negativ ____
    CONTACÞI: numãr declarat ____ numãr depistaþi ____ numãr
testaþi ____ din care pozitivi _____
 ________________________________________________________________
______________
| DATE STRICT CONFIDENÞIALE (nu se introduc în baza de
date)                   |
|                                                                 
             |
| DATA ÎNCEPERII TRATAMENTULUI
____/____/______                                |
|                                                                 
             |
| EFECTUAT ÎN: Spital ____ Ambulatoriu de specialitate _______
Cabinet MF ____ |
|                                                                 
             |
| Alte (precizaþi)
___________________________________________________________ |
|                                                                 
             |
| MEDIC DE FAMILIE: Nume _____________ Prenume _____________
Judeþ ___________ |
|                                                                 
             |
| Localitate ___________________ Necunoscut
________________                   |
|                                                                 
             |
| Anunþat asupra pacientului: DA ____ NU
____                                  |
|                                                                 
             |
| FÃRÃ MEDIC DE FAMILIE
_____                                                  |
|                                                                 
             |
| DSP a anunþat cel mai apropiat medic de familie sau
asistenþii               |
|                                                                 
             |
| medico-sociali: DA _____ NU
____                                             |
|                                                                 
             |
| Dacã DA: Nume __________________ Prenume ________________ Judeþ
____________ |
|                                                                 
             |
| Localitate
_____________________                                             
|
|
_________________________________________________________________
_____________|
 
    Data completãrii ____/____/_______
    Semnãtura ºi parafa                             Semnãtura ºi
parafa
    Medic dermato-venerolog                         Medic
epidemiolog