Republic of the Philippines

Department of Health
REGIONAL OFFICE IV-B MIMAROPA
QMMC Compound, Project 4, Quezon City

STI Reporting Form

MONTH: CITY: _____________________________________________________________
YEAR: NAME OF SHC: _____________________________________________________________
REGION: NAME OF SHC PHYSICIAN: _____________________________________________________________

3.1 HIV 3.2 Syphilis 3.3 Hepatitis B 3.4 Gonorrhea & Non-gonococcal Infections

Number of Number of Number

Number of Number Number of Number of Number of Number of Number Number Number of Number of Number of
Number of Number of non- screening Number of Number Number Number Number of Number of Number of Number Number of
HIV post- of non- screening HIV tests syphilis of of gram gonorrhea positive NGI
HIV pre-test HIV reactive tests referrals to of RPR of tests of RPR of TPPA/ TPPA/TP Hepatitis B first dose of gram gram stains
Clients test reactive tests confirmato positive treatment reactive stain treatment for treatment
counseling screening HIV confirmed treatment tests reactive results TPHA HA screening Hepatitis B stains w Gm(-)
counseling results reactive to ry results for TPPA/ courses for HBsAg results courses Trichomon courses
done tests done screening positive for hub done for RPR given done results done vaccinations done diplococci
done given Anti-HIV given TPHA provided tests given provided iasis provided
tests HIV given

TOTAL A B C D E F G H I J K L M N O P Q R S T U V W X Y
Pregnant
F
Registered Sex
Female
Worker
M Male

Non- Pregnant
registered F
Establishment- Female
Based Sex
Worker M Male

Pregnant
Freelance Female
Sex Worker
Female

MSM Male

TGW Male

Pregnant
F
IDU Female

M Male

Pregnant
Female Partner of
MSM or IDU
Female

Pregnant
OFW / F
Partners of Female
OFW
M Male

Pregnant
F
Others Female

M Male
Note: 'Total Females' includes the number of pregnant if data for pregnant are available