NAME: ______________________________________________________ CLASS YR: _____________ DATE: ______/______/_____

S: CC: ___________________________________________________________________________________________________________________
 

Symptoms	Yes	No	Duration, Character, Location
Vaginal Discharge
Itching
Burning
Odor
Lesions/ulcers
Dysuria
Abd. pain
Sexually active
B.C. method
menses regular			LMP / /
Partner symptomatic			N/A

 

Other:

Current meds Allergies
 

PMH		UTIs	STDs	Yeast Inf.	Bact. Vagin.	PID	GYN Surg.	Other
	YES
	NO

 

O:		WNL	ABN	Describe
Temp
Vulva
Vagina
Cervix
Bi-man	Uterus
	Adnexa
Rectal
Back
Abd.
Other

 
 
 
 
 
 
 

NAME:
 
 
 

W.P./KOH	WBC	RBC	Bacteria	Clue Cells	Trich	Yeast	Amine test	Ph	Other
#/HPF

 

U/A if appropriate Not applicable
 

Dipstix		Leu	Nit	Urobi	Prot	pH	Bl	SpGr	Ket	Bili	Glucose
Micro	color	Charac		WBC	RBC	Bact	Epi	other	acceptable
									Unacceptable

 

Labs sent: None Chlamydia GC Herpes Pap Other
 

A:
 

P: OTC Yeast Preparation

Terazol 3/7 cream/suppositories

Diflucan 150mg. 1 po x 1 dose

Metronidazole 500 mg. bid x 7 days; or 500mg #4 (2 grams) stat

Metronidazole gel 0.75% 1 applicator intravaginally qhs x 7 days

Clindamycin 300mg po bid x 7 days

Clindamycin cream 2% 1 applicator intravaginally qhs x 7 days

Doxycycline 100 mg. bid x 7 days

Azithromycin 1 gm. po x 1 dose

Erythromycin 500 mg qid x 7 days

Other:
 

Procedure: Trichloracetic acid Podophyllin
 

Other: Warned of poss. interaction between antibiotics and oral contracept.

Educational materials given

RTC

Partner to come in

Referred to:

Appt. date / / time:
 
 
 
 
 
 
 
 
 
 
 

Date / / Time: Signature