Get the free Congenital Syphilis Form - CDC - wwwn cdc

Local Use OnlyMothers Name: Chart No: Mothers Case ID No: Address: OB×Gun: Phone No: () (Number, Street, City, State)(Zip code×Infants Name: Pediatrician: Centers for Disease Control and Prevention,

How to fill out congenital syphilis form

How to fill out a congenital syphilis form:

1. Obtain the form: You can request the congenital syphilis form from your healthcare provider or local health department. They may provide a physical copy or allow you to download it online.
2. Gather necessary information: Before filling out the form, gather all relevant information about the mother and baby. This may include their names, dates of birth, contact information, medical history, and any previous syphilis treatment.
3. Complete the patient information section: Begin by filling out the patient information section at the top of the form. Include the mother's and baby's names, addresses, phone numbers, and dates of birth.
4. Provide medical history: In the next section, provide details about the mother's medical history, including any previous pregnancies, syphilis test results, and treatment history. Also, provide information about the baby's medical history, including the date of birth, weight, and any symptoms or complications related to congenital syphilis.
5. Document laboratory results: If available, include the results of any syphilis tests conducted on the mother during pregnancy or on the baby after birth. Specify the type of test performed, the date of the test, and the results.
6. Describe treatment: Indicate whether the mother or the baby received treatment for congenital syphilis. Specify the dates and types of treatment administered, including any medication and dosages prescribed.
7. Note follow-up actions: If there are any subsequent actions required, such as additional tests or follow-up appointments, document them in this section. Include any recommendations or referrals made by healthcare providers.

Who needs a congenital syphilis form?

1. Pregnant women: Pregnant women who have been diagnosed with syphilis, regardless of the stage, are required to complete a congenital syphilis form. This documentation is crucial for monitoring and managing the health of both the mother and the baby.
2. Healthcare providers: Healthcare providers, including doctors, nurses, and midwives, need congenital syphilis forms to accurately record and report cases of syphilis in pregnant women and their infants. These forms help track the progress of treatment and ensure appropriate follow-up care.
3. Public health departments: Local health departments utilize congenital syphilis forms to monitor the prevalence of syphilis and its impact on the community. These forms help identify trends, allocate resources for prevention and treatment, and implement public health interventions effectively.

For pdfFiller’s FAQs

What is congenital syphilis form?

Congenital syphilis form is a document used to report cases of syphilis in newborns.

Who is required to file congenital syphilis form?

Healthcare providers, medical facilities, and laboratories are required to file congenital syphilis form.

How to fill out congenital syphilis form?

Congenital syphilis form should be filled out with information about the newborn, the mother, and the diagnosis of syphilis.

What is the purpose of congenital syphilis form?

The purpose of congenital syphilis form is to track and monitor cases of syphilis in newborns for public health surveillance.

What information must be reported on congenital syphilis form?

Information such as newborn's demographics, mother's syphilis status, treatment received, and laboratory test results must be reported on congenital syphilis form.

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