Delaware Confidential Morbidity Report–Sexually Transmitted Diseases
Patient Name
SSN
Age
Sex
Phone
Date of Birth
Patient Address
City
State
Zip
Pregnant
Yes
No 
Unknown
Prev 12 months
Race
White
Asian/Pacific Islander
Unknown
Black
American Indian/Alaskan Native
Ethnicity
Hispanic
Non-Hispanic
Marital Status
Married 
Single
Other/Unknown 
Laboratory Tests 
N. gonorrhea
Confirmed Positive
by 
Presumptive Positive
Beta Lactamase   
Positive   
Negative 
Date
C. trachomatis
Confirmed Positive
by 
Date 
Syphilis
RPR   
Reactive 
dls
Non-reactive
VDRL          
Reactive
dls
TP-PA         
Reactive
Non-reactive
FTA-ABS    
Reactive                   
Non-reactive
Other      
Date

Reported by: 
Laboratory Name                                 
Phone
Address
Date Reported 
Diagnosis (2)  
Syphilis  
Primary
Secondary
Early latent less than 1 year
Late latent greater than 1 year
Congenital 
Neurosyphilis
Chlamydia (check all that apply)
Asymptomatic
Symptomatic
Pelvic Inflammatory Disease
Conjunctivitis
Other
Site
Cervix
Urethra
Other
Gonorrhea (check all that apply)
Asymptomatic
Symptomatic
Pelvic Inflammatory Disease
Disseminated
Conjunctivitis
Antibiotic resistant
Other             
Site
Cervix
Urethra
Rectum
Pharynx
Other 
Other STDS 
NGU
Herpes
Chancroid
Mucopurulent Cervicitis
HIV
Granuloma inguinale
Human Papilloma Virus
Lymphogranuloma Venereum
Other 
Congenital Syphilis (4)
Infant Information
Live Birth Weight in grams 
Still birth   
Born alive, then died  
Date
Estimated gestation age in weeks
Darkfield Positive
Long Bones X-rays    
Positive    
Negative
CFS   
VDRL     
Reactive      
Non-reactive
WBC >5/mm3        
Yes    
No
Protein >50 mg/dl  
Yes    
No
Hepatosplenomegaly
Cutaneous lesions
Snuffles
Asymptomatic
Other 
Maternal Information
Mother’s Name 
Medical Record Number 
Mother’s Birth Date 
Mother’s Race   
White       
Black
American Indian/Alaskan Native
Asian/Pacific Islander
Ethnicity           
Hispanic    
Non-Hispanic
Mother’s Diagnosis 
Stage
by 
Physician Name
Prenatal Care Date First Visit
Total number of visits 
No Prenatal Care   
Mother’s Serology History
Date
Titer
Date
Result
RPR
FTA
RPR
TP-PA
RPR
Treatment (5) 
Based upon Diagnosis section 2
Date 
2.4 mu Benzathine Pen G
7.2 mu Benzathine Pen G
Ceftriaxone Sodium
125mg
250mg
Ciprofloxacin 500 mg
Azithromycin 1 gm
Doxycycline 100 mg 
BID 
7 days
14 days
Other
Other Treatment and Dosage 

Reported by (6)                                                                         Date 
Name
Facility
Address
City
State
Zip
Phone
For a copy of Delaware’s reporting regulations 
or for additional information/referral/cards, 
please contact the Delaware STD Program Office at 
417 Federal Street, Dover, DE 19901 or 
by phone at (302) 744-1025
Revised March 2009
Doc. #35-05-20/07/08/08