About this template
The STI Clinical Report Form is designed for healthcare professionals to streamline the documentation of patient symptoms, diagnostic findings, and treatment plans. By moving away from manual paper records, clinics can maintain a more organized, searchable, and efficient database of patient encounters while ensuring that critical health information is captured consistently during every visit.
This template covers essential patient demographics, clinical history, symptom onset, and diagnostic details. It is built to help medical staff reduce administrative overhead, allowing them to focus more on patient care. Whether you are operating a private practice, a community health clinic, or a telehealth service, this form provides a structured approach to reporting that supports better clinical decision-making and follow-up care.
Key features
- Standardized fields for symptom tracking and diagnosis.
- Mobile-responsive layout for use on tablets or laptops.
- Clear sections for patient history and clinical notes.
- Easy integration with spreadsheet tools for data analysis.
- Eliminates manual data entry and reduces paperwork errors.
Use cases
- Documenting new patient STI screenings and consultations.
- Tracking symptom progression during follow-up appointments.
- Compiling clinical data for internal quality audits.
- Streamlining intake for community sexual health clinics.
What this form collects
- Patient Full Name (Short answer)Enter the patient's legal first and last name.
- Date of Birth (Date)Format: MM/DD/YYYY
- Contact Information (Short answer)Provide the best phone number or email for patient follow-up.
- Symptom Details (Paragraph)Describe the symptoms reported by the patient.
- Symptom Onset Date (Date)When did the patient first notice these symptoms?
- Specimen Source (Short answer)Indicate the site from which the specimen was collected.
- Preliminary Diagnosis (Dropdown)Select the primary diagnosis based on clinical assessment.
- Physician Notes (Paragraph)Enter any additional clinical observations or treatment plans.
- Attending Physician Name (Short answer)Full name of the provider completing this report.
FAQ
Is this form suitable for all healthcare settings?
Yes, this template is highly adaptable for private practices, clinics, and telehealth providers who need a structured way to document patient encounters.
Can I customize the fields in this form?
Absolutely. You can easily add, remove, or modify questions within the Google Form editor to match your specific clinic's diagnostic protocols.
How can I ensure patient data remains organized?
All responses are automatically collected in a linked Google Sheet, allowing you to filter, sort, and analyze patient data efficiently.
Is this form mobile-friendly?
Yes, Google Forms are natively responsive, meaning you can access and fill out this form on any smartphone, tablet, or desktop computer.
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.