Delaware Public Health Laboratory					Affix CT/GC DNA
30 Sunnyside Road							Barcode Label Here
Smyrna, DE  19977
Phone: (302) 223-1520  • Fax: (302) 653-2877

MCI#:______________ Agency Name:_________________________________________ Collection Date:______________

Name:____________________________________________________________________ Phone:_____________________ 
(Print Clearly)       (Last)			(First)

Address:_____________________________________________________________________________________________ 

City:_________________________ State:____________ Zip:_______________ Birth Date:__________________________

(Check all that apply):
Race: __ American Indian or Alaskan Native	__ Asian	__ Black	Gender:	__ Female
      __ Native Hawaiian or Pacific Islander	__ Other Race	__ White		__ Male

Ethnicity:  __ Hispanic		__ Non-Hispanic		__ Unknown

Reason for Test:__Screening __Annual __STD Symptoms __Suspected STD contact __Known STD contact __Other

Clinician (Name and ID#):_______________________________________________________  ICD-9:_________________

Insurance Status: 	  __ Private   __ Medicaid-Delaware Physician's Care, Inc. __ Medicaid-Diamond State
		  __ Medicaid-Fee for Service   __ Uninsured  __ Unknown __ Medicaid #___________________

TEST REQUESTED

Microbiology
___ Chlamydia and GC DNA Amplification: Cx / Urethra / Urine
___ Syphilis - RPR
___ Syphilis - Confirmatory TPPA (includes RPR)
___ Syphilis - FTA (Sent Out)
___ Syphilis - VDRL (CSF Only)
___ Gonorrhea Culture - Source:______________________________________
___ Urine Culture
___ Throat for Strep Only
___ Bacterial Culture (Misc., wound, genital, respiratory) 
    Source:__________________________________________________________
___ Stool Culture
___ Stool Culture to Rule Out Salmonella / Shigella
___ Ova and Parasites
___ Serotype Organism:__________________  Source:____________________
___ AFB Culture and Smear		  Source:____________________
___ AFB Smear Only			  Source:____________________

Virology
___ Viral Culture         Source:______________________________________
___ Herpes Culture        Source:______________________________________
___ HIV	EIA/Confirmation  Source:______________________________________
___ Influenza Culture     Source:______________________________________
___ Organism Isolate      Source:______________________________________
___ CSF Culture Profile
___ WNV IgM	___ WNV IgG
___ Hepatitis A Antibody IgM and IgG
___ Hepatitis B Surface Antibody
___ PCR for:___________________________________________________________
    ___________________________________________________________________
    ___________________________________________________________________
    ___________________________________________________________________
								
Rapid / Clinic Tests
___ Rapid HIV: Blood / Oral	___ GC Gram Stain (males only)
___ Hgb S (Sickle Cell Screen)	___ HgB		___ Stat RPR

Chemistry - Blood Lead
___ Screen		___ Confirmation	___ Post Confirm repeat
Risk:			___ Low			___ High
Sample Type:		___ Venous		___ Capillary
Screened in:		___ CHC (65)		___ WIC (58)	___ Other (62)
Hgb: ______________


GONORRHEA / CHLAMYDIA DNA AMPLIFICATION QUESTIONS FOR YOUTH THROUGH AGE 18

#Sexual partners during past 6 months?	__________

Had STD education in school?		Yes	No
Past history Syphilis?			Yes	No
Past history Chlamydia?			Yes	No
Past history Gonorrhea?			Yes	No
Past history other STD?			Yes	No
Females-history of previous PID?	Yes	No
Females-previous pregnancy?		Yes	No
Under influence of drugs or alcohol
during last sexual encounter?		Yes	No
Used a condom last sexual encounter?	Yes	No


Check Contraceptive Method Used in Last Sexual Encounter:

___ Abstinence
___ Condom
___ Condom and Spermicides
___ Diaphragm
___ Injectable contraceptive
___ IUD
___ Oral Contraceptive
___ Spermicides
___ No Method
___ Other _________________________________________________________________

Order Number:____________________________

Manual test requisition form updated 010108.
Doc # 35-05-20/08/01/01