About this template
In clinical practice, managing sensitive patient data requires precision, clarity, and efficiency. The Sexually Transmitted Infection Report Form is designed for healthcare providers, clinics, and medical staff to systematically collect patient details, document reported symptoms, and record official diagnoses. Moving away from cumbersome paper forms helps medical practices reduce administrative overhead and streamline their reporting workflows.
This template captures essential clinical information, including vital biometrics, detailed symptom timelines, reproductive health markers, specimen sources, and formal physician notes. By standardizing the intake and reporting process, medical teams can maintain accurate records, track patient histories effectively, and ensure that all necessary diagnostic details are captured securely.
Doc2Form allows healthcare practices to instantly convert documents like this into ready-to-use Google Forms, making digital intake fast and accessible. Whether you are managing an urgent care facility, a sexual health clinic, or a general practice, this template provides a structured foundation for gathering critical patient information while maintaining organized records in Google Drive.
Key features
- Capture complete patient demographic and biometric details.
- Log symptom onset dates, frequencies, and specific descriptions.
- Record laboratory specimen sources and formal physician diagnoses.
- Streamline clinical intake and eliminate physical paperwork.
- Maintain structured digital records directly in Google Sheets.
Use cases
- Sexual health clinic patient consultations and diagnostic reporting.
- Urgent care tracking of symptomatic patient visits.
- Public health data collection and institutional record-keeping.
What this form collects
- Patient Full Name (Short answer)Enter the patient's first and last name.
- Date of Birth (Date)Enter the patient's date of birth.
- Age (Short answer)Enter current age in years.
- Height and Weight (Short answer)Enter height and weight for clinical baseline records.
- Phone Number (Short answer)Enter the best contact phone number for follow-up.
- Email Address (Short answer)Enter the patient's email address.
- Home Address (Paragraph)Enter the patient's residential address.
- Marital Status (Dropdown)Select the patient's current marital status.
- Pregnancy Status (Multiple choice)Indicate if the patient is currently pregnant.
- Currently Due Date (Date)If pregnant, enter the estimated due date.
- Date of Last Menstrual Cycle (Date)Enter the start date of the last menstrual cycle.
- Current Birth Control Method (Short answer)List any contraceptive methods currently in use, if applicable.
- Reported Symptoms (Paragraph)Describe all symptoms the patient is currently experiencing.
- Symptom(s) Start Date (Date)Enter the date when symptoms first appeared.
- Symptom Frequency (Multiple choice)Indicate how frequently the symptoms occur.
- Specimen Source (Short answer)Specify the source of the lab specimen tested.
- STI Diagnosis (Short answer)Enter the confirmed or suspected STI diagnosis.
- Physician Full Name (Short answer)Enter the name of the reporting physician.
- Date Reported (Date)Enter today's date.
- Physician Notes (Paragraph)Provide any additional clinical observations, treatment plans, or remarks.
- Physician Signature (Paragraph)Please paste a link to your signed document (Google Drive, Dropbox, etc.) or type your full legal name to serve as an electronic signature.
FAQ
What is the primary purpose of this STI report form template?
It is designed to help healthcare providers systematically collect patient history, document symptoms, and record formal diagnoses in a standardized digital format.
Can I customize the questions on this Google Form?
Yes. Once you convert or open the template in Google Forms, you can fully edit, add, or remove questions to suit your clinic's specific reporting protocols.
How does digitizing this form improve clinical workflow?
It eliminates manual data entry, reduces the risk of misplaced paperwork, and automatically organizes all submissions into a searchable Google Sheet for easy review.
Can patients fill out this form on their mobile devices?
Yes, Google Forms are fully responsive and work seamlessly on smartphones, tablets, and desktop computers.
How do I get started with this template using Doc2Form?
Simply use Doc2Form to instantly convert your existing intake documents or protocols into a functional Google Form in seconds.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.