Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017
Name: ________________________________
North Carolina ID: ______________________
CDC ID: ______________________________
CDC Study ID: ___________________________________
Charts Reviewed:
Clinic: _________________________ Date of Visit: __ __- __ __- __ __ □ Chart Requested □ Chart Abstracted
Clinic: _________________________ Date of Visit: __ __- __ __- __ __ □ Chart Requested □ Chart Abstracted
Clinic: _________________________ Date of Visit: __ __- __ __- __ __ □ Chart Requested □ Chart Abstracted
Clinic: _________________________ Date of Visit: __ __- __ __- __ __ □ Chart Requested □ Chart Abstracted
Clinic: _________________________ Date of Visit: __ __- __ __- __ __ □ Chart Requested □ Chart Abstracted
Clinic: _________________________ Date of Visit: __ __- __ __- __ __ □ Chart Requested □ Chart Abstracted
Clinic: _________________________ Date of Visit: __ __- __ __- __ __ □ Chart Requested □ Chart Abstracted
Clinic: _________________________ Date of Visit: __ __- __ __- __ __ □ Chart Requested □ Chart Abstracted
Clinic: _________________________ Date of Visit: __ __- __ __- __ __ □ Chart Requested □ Chart Abstracted
Clinic: _________________________ Date of Visit: __ __- __ __- __ __ □ Chart Requested □ Chart Abstracted
Date of syphilis diagnosis (mm/yyyy): __ __ - __ __ - __ __ __ __
Date of ocular syphilis diagnosis (mm/yyyy): __ __ - __ __ - __ __ __ ___
Demographics:
1:
Patient’s sex
1: Male 2: Female 3: Transgender 4: Unknown
2:
Patient’s age at time of diagnosis: __ __ __ years of age
3:
Race/ethnicity:
1:
White 2: Black 3: Hispanic or Latino 4: Asian
5: Native
Hawaiian/Other Pacific Islander 6: American Indian or Alaska Native
Syphilis Information:
4:
Does patient report or have documented history of syphilis prior to
this episode?
1: Yes 2: No 3: Unknown
5: If Yes:
Approximate date of previous syphilis infection: (mm-yyyy) __ __ -
__ __ __ __
6:
What stage of syphilis did patient have at time of ocular syphilis
diagnosis?
1:
Primary syphilis 2: Secondary syphilis 3: Early latent 4:
Late latent
7:
What was the patient’s syphilis serology result at the time of
ocular syphilis diagnosis? Please
circle “Yes” for all tests performed and provide test
result and date of test
RPR
Yes No Result (titer):
Date of test:
mm/dd/yyyy
VDRL
Yes No Result (titer):
Date of test: :
mm/dd/yyyy
EIA
Yes No Result:
Date of test: :
mm/dd/yyyy
TP-PA
Yes No Result:
Date of test: :
mm/dd/yyyy
FTA-ABS
Yes No Result:
Date of test:
mm/dd/yyyy
Other-
Type of test: Result: Date of
test: mm/dd/yyyy
8:
Did
the patient have or report recent history of any symptoms that could
be associated with primary or secondary syphilis?
1: Yes 2: No 3: Unknown
9:
If
yes, please detail symptoms patient reported:
Choose as many as apply:
1: Chancre/genital lesion 2: Skin
rash 3: Lymphadenopathy/swollen lymph nodes
4:
Alopecia 5: Other:
_____________________________________________________
10: Did the patient have a diagnosis of neurosyphilis?
1: Yes 2: No 3: Unknown
11:
Did
the patient have any extraocular neurologic symptoms?
1:
Yes 2: No 3: Unknown
12: If yes, please detail neurologic symptoms patient reported: (e.g. headache, neck stiffness): __________________________________________________________________________________________
13: Did patient have a lumbar
puncture (LP) performed?
1: Yes 2: No 3: Unknown
14:
If yes LP was performed please answer the following questions:
1: CSF VDRL result ____________________
2: CSF FTA-abs ____________________
3:
CSF WBC ____________________
4: CSF total
protein ____________________
5: CSF glucose ____________________
15:
What treatment did patient receive and what was the duration?
1: Benzathine
penicillin G Doses
_____________________
2: Aqueous crystalline penicillin G
IV Duration (days) ____________
3: Procaine
penicillin Duration (days)_____________
4: Ceftriaxone 2
g daily either IM or IV Doses _____________________
5:
Other _______________________________
HIV Information:
16:
Patient’s HIV status:
1: HIV-infected Approximate year of diagnosis (yyyy) __ __ __ __
2: HIV-uninfected Date of most recent negative HIV test if known:
(mm-yyyy) __ __ - __ __ __ __
3: Unknown
17:
If HIV-uninfected, was the patient on PrEP?
1: Yes 2: No 3: Unknown
Question 6-8: If HIV-infected:
18:
Was this a new diagnosis, concurrent with syphilis diagnosis?
1: Yes 2: No 3: Unknown
19:
Was patient on cART at time of diagnosis?
1: Yes 2: No 3: Unknown
20: Patient’s most recent CD4 count: _____________
21:
Patient’s most recent viral load: ______________
22:
What HIV medication has the patient been on in the last 5 years:
Medication:
_____________________________ Dates on medication:
______________________
Medication:
_____________________________ Dates on medication:
______________________
Medication:
_____________________________ Dates on medication:
______________________
Medication:
_____________________________ Dates on medication:
______________________
Medication:
_____________________________ Dates on medication:
______________________
23:
During the course of this illness, where did the patient seek
treatment?
1:
STD or HIV Clinic 2: Infectious Disease Clinic 3: Eye Clinic
4: Emergency Room 5: Primary Care Clinic 6: Admitted as
inpatient
Sexual Behavior Questions:
24:
Gender of the patient’s sexual partners
1: Men only 2: Women only 3: Both men and women 4: Unknown
If patient reports MSM behavior:
25:
In the past 12 months, with how many different men has the patient
had oral or anal sex? _____
_____ _____
26: In the past 12 months, with how many different men has the patient had anal sex? _____ _____ _____
27: In the past 12 months, with how many different men has the patient had oral sex? _____ _____ _____
28: How often does the patient say they use condoms?
1: All/most of the time 2: Some of the time 3: Never or almost never
29:
In the past 12 months, has the patient exchanged drugs or money for
sex?
1: Yes
2: No 3: Unknown
30:
Does the patient report using the internet or apps/social media to
meet sexual partners?
1: Yes 2: No 3: Unknown
31:
(Females only). In the past 12 months, has the patient had sex with
a person who is known to her to be an MSM?
1: Yes 2: No 3: Unknown
32:
In the past 12 months, has the patient engaged in injection drug
use?
1: Yes
2: No 3: Unknown
33: In the past 12 months,
has the patient used any of the following injection or non-injection
drug?
1: Crack
2: Cocaine 3: Heroin 4: Nitrates/Poppers 5: Methamphetamines
6: Other: _________________________________________________________________________________
34: In the past 12 months has the patient used erectile dysfunction medications?
1: Yes 2: No 3: Unknown
35:
In the past 12 months, has the patient been incarcerated?
1: Yes 2: No 3: Unknown
36:
In the past 12 months, has the patient been diagnosed with another
STD?
1: Yes
2: No 3: Unknown
37: If yes: what was
patient diagnosed with:
1: Syphilis 2: Gonorrhea 3: Chlamydia 4: Trichomonas 5: HSV
38:
In the past 12 months, has the patient traveled?
1: Yes, but only within the United States 2: Yes,
internationally 3: No 4: Unknown
39:
If yes to travel, do they report sexual contacts during the travel?
1: Yes 2: No 3: Unknown
Ophthalmologic Exam:
40:
Did
the patient have an ophthalmologic exam?
1: Yes 2: No 3: Unknown
41: Date of first ophthalmologic exam: (mm-dd-yyyy) __ __-__ __-__ __ __ __
42:
What were the patient’s ocular symptoms?
Choose as many as apply. Please detail, including length of
symptoms.
1: Eye pain Details:
_____________________________________________
2: Red
eye Details: _____________________________________________
3: Blurry vision/Change in vision Details:
_____________________________________________
4: Partial
vision loss Details:
_____________________________________________
5: Loss of
functional vision in 1 eye Details:
_____________________________________________
6: Loss of
function vision in both eyes Details:
_____________________________________________
7: Other visual
symptoms Details: _____________________________________________
8: Unknown
43:
Detail pertinent findings, diagnoses and date of exam:
Choose as many as apply:
1: Scleritis/Keratitis
Details: _________________
2:
Uveitis: Details: _________________
3: Chorioretinitis
Details: _________________
4: Optic Neuritis Details:
_________________
5: Retinal Detachment Details:
_________________
6: Other ocular findings Details:
________________________________________________________
44:
If yes to Uveitis, was it:
1: Anterior Uveitis 2: Posterior Uveitis 3:
Panuveitis
45:
What was the patient’s visual acuity at presentation?
1: Left eye: 20/________
2: Right eye: 20/________
46: Which eye was involved?
1: Left eye only 2: Right eye only 3: Both eyes 4: Unknown
Follow-up Ophthalmologic Exam:
47: Did the patient have a follow up eye exam(s)?
1: Yes 2: No 3: Unknown
48: Date of most recent follow up ophthalmologic exam: (mm-dd-yyyy) __ __-__ __-__ __ __ __
49:
What was the patient’s visual acuity at most recent
follow-up?
1:
Left eye: 20/________
2: Right eye: 20/________
50:
Did the patient’s ocular symptoms improve following
treatment?
1:
Yes, symptoms completely resolved 2: Yes, but still with residual
deficit 3: No
Public reporting burden of this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Oliver, Sara Elizabeth (CDC) |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |