Monthly STD
Unique ID. No. of STD Clinic/Gynae OPD
MONTHLY REPORT FORMAT FOR STI CLINICS
Name of STD Clinic/ Hospital to which
the Gynaecology OPD is Attached
Sub Type Category Location
Address :
District: Block City:
Reporting Period: Month(MM) Year(YYYY)
Name and phone no. of Officer In - charge:
Name of Centre/service provider
A. No. of Patients Availed STI services in this month
Age Group & Sex
Total
Type of Patients 44
Male Female Other Male Female Other Male Female Other Male Female Other Male Female Other
First clinic visit (for the index
STI/RTI complaint)
0 0 0
First clinic visit (for no STI/RTI
complaint)
0 0 0
Repeat STI/RTI visit for the index
STI/RTI complaint
0 0 0
Total No of visits 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
B. STI syndromic diagnosis
(Should be filled by all STI/RTI service providera for first clinic visit only)
Diagnosis Male Femal Other Total
1.Vaginal/ Cervical Discharge(VCD) e 0
2.Genital Ulcer (GUD)-non herpetic 0
3.Genital ulcer(GUD) – herpetic 0
4.Lower abdominal pain(LAP) 0
5.Urethral discharge(UD) 0
6.Ano-rectal discharge (ARD) 0
7.Inguinal Bubo(IB) 0
8.Painful scrotal swelling (SS) 0
9.Genital warts 0
10.Other STIs 0
11. Asymptomatic STI treatment 0
12 No of people living with HIV/AIDS (PLHAs) attended with STI/RTI during the month 0
Total No of cases 0 0 0 0
Do you have all essential STI drugs and/or STI pre-packed kits? (1= Yes or 2 = No)
C. Details of other services provided to patients with STI complaints in this month
To be filled in by all RTI/STI Service Providers
Male Femal Other Total
Service e
1. Number of patients counseled 0
2. Number of condom provided 0
3. Number of RPR tests conducted 0
4. Number of found reactive 0
5. Number of Partner notification undertaken 0
6. Number of partners managed 0
7. Number of patients referred to ICTC 0
8. Number of found HIV-infected (of above) 0
9. Number of patients referred to other services 0
NACO CMIS
Monthly STD
Unique ID. No. of STD Clinic/Gynae OPD
D. STI service provision HRGs in the month (To be filled in by NGO STI Clinic)
Male Female Trangenders Total
Number of new individuals visited the clinic 0
Number of presumptive treatments provided for gonococcus
0
and chaymydia
Number of regular STI check-ups conducted 0
E. ANC syphilis screening in this month
Should be filled by all service providers with ANC service provision Total
Number of ANC first visits in the month
Number of rapid plasma reagin (RPR) or venereal disease research laboratory (VDRL) test performed
Number of RPR/VDRL reactive
Number of RPR/VDRL reactive confirmed with TPHA
Number of pregnant women treated for syphilis
F. Laboratory diagnosis of STIs
Type of Disease Laboratory Tests Male Female Other Total
1. Total RPR/VDRL test performed 0
RPR test reactive >= 1:8 0
Number of RPR reactives confirmed with TPHA 0
2. Total Gram stain performed 0
Gonococcus + (gram negative intracellular
0
diplococci +)
Non - Gonococcus ursthritis (NGU)-Pus cells +ve 0
Non - Gonococcus cervicitis (NGC)-Pus cells +ve 0
None 0
Nugents score +ve 0
3. Wet mount test performed 0
Motile Trichomonads +ve 0
Whiff test +ve 0
Clues cells + 0
None 0
4. KOH test performed 0
5. Availability of test kits, reagents and consumables (Yes =1, No=2)
RPR kits
TPHA kits (wherever applicable)
Reagent for gram stain
Reagents wet mount and KOH test
CMIS NACO
Monthly STD
Unique ID. No. of STD Clinic/Gynae OPD 0
Human resource details at STI/RTI and /or Gynaecology clinics (Should be filled by all STI/RTI clinics)
Details of Staff at the STI/RTI or Gynaecology clinics
Whether received
Whether Specialised
training on RTI/STI Month and year of Last
Sex 1=Male in skin and venereal
case management as training (MMYY)
2=Female disease (VD) (1=Yes
per national guidelines (0207)
2=NO)
(1=Yes 2=NO)
Medical officer
Medical officer
Medical officer
Laboratory technicians
Laboratory Attandent
Medico social worker
Counselor (in house or attached to ICTC)
CMIS NACO