Kentucky Reportable Disease Form
Gonorrhea . Genital, uncomplicated Ophthalmic Penicillin . Chlamydia . Pharyngeal PID/Acute Tetracycline . Chancroid ... Collection . Laboratory Name . Type of Test : Results . Treatment Date : Medication . Dose : If syphilis, was previous treatment given for this infection? Yes No If yes, give approximate date and place_____ _____ ... ................
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