ALABAMA DEPARTMENT of PUBLIC HEALTH
 
STD/HIV Morbidity Card

Patient's County


* Patient's Last Name

* Patient's First Name

Patient's Middle Name

* Patient's Address

* Patient's City

* Patient's State


Other:

* Patient's Zip

* Patient's DOB

Patient's SSN

Patient's Phone Number

* Patient's Race


Patient's Ethnicity


* Patient's Sex

Male Female

Patient's Marital Status


* Reportable Disease/Condition


Other:

Qualitative Results

Positive/Reactive Negative/nonreactive

* Provider's Name

Syphilis Quantitative Results

Reported By


* Provider's Address

* Provider's City

* Provider's State

* Provider's Zip

Treatment

Treatment Date

* Exam Date

* Test Sites


* Lab Report Date

* Lab Name

Lab Accession Number

Comments



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Alabama Department of Public Health