Tools Load unfinished survey Resume later Language: English - English English - English Français - French Nederlands - Dutch default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. Sentinel General Practitioners - STI, hepatitis B and C Any new episode of the following 5 STIs (sexually transmitted infections), after confirmation by the laboratory (except for condylomas and genital herpes, for which a clinical diagnosis is sufficient), and/or a new diagnosis of hepatitis B or C. 1. Identification (This question is mandatory) GP code Only numbers may be entered in this field. (This question is mandatory) Startdate of consultation week (monday) Date format: mm-dd-yyyy Open date/time selector Format: mm-dd-yyyy 1900-01-01 2187-12-31 23:59:59.999 MM-DD-YYYY (This question is mandatory) Sex patient Choose one of the following answers men women intersex Gender patient Choose one of the following answers cisgender transwoman transman non-binary other No answer (This question is mandatory) Age of the patient: Only numbers may be entered in this field. Your answer must be between 0 and 110 (This question is mandatory) Which type of IDcard your patient possess? Choose one of the following answers Please choose... Belgian IDcard other identity card or residence permit issued in Belgium or other EU member state illegal migrant / without a valid residence permit tourist no answer (This question is mandatory) What is currently the patient's disease cost coverage? Choose one of the following answers Please choose... classic compulsory medical care insurance classic compulsory insurance with increased insurance allowance urgent medical assistance, social services of PCSW, Fedasil insurance of another country, private insurance none unknown/I don't know (This question is mandatory) Was patient born abroad? Choose one of the following answers Please choose... No Yes - other European country Yes - Sub-Saharan Africa Yes - North Africa Yes - Asia, including Turkey Yes - Central & South America Yes - North America Yes – Oceania Yes – Unknown (This question is mandatory) Level of education patient? Choose one of the following answers primary education secondary education higher education unknown The patient has sexual contact with: Choose one of the following answers Men Women Men and Women No recent sexual contact Other No answer 2. Diagnostic (This question is mandatory) Who initiated the STI test? Choose one of the following answers you, as general practitioner the patient (This question is mandatory) The registration concerns : * Only patients in whom you diagnose a new acute or chronic hepatitis B or C infection must be reported. This also applies to re-infections with hepatitis C after a previous cure. Patients in whom hepatitis is already known do not need to be reported. Choose one of the following answers An STI diagnosis A diagnosis of hepatitis B or C* (This question is mandatory) Diagnosis STI: *Reinfection = an STI in a patient with a history of infection with the same pathogen, unrelated to the current episode. For genital warts and genital herpes, the term ‘reinfection’ can be interpreted as a reactivation of the infection. First infection Reinfection Not applicable Chlamydia First infection Reinfection Not applicable Gonorrhoea First infection Reinfection Not applicable Condylomata First infection Reinfection Not applicable Syphilis First infection Reinfection Not applicable Genital herpes First infection Reinfection Not applicable (This question is mandatory) Diagnosis: Acute infection Chronic infection Unknown stage of infection Not applicable Hepatitis B Acute infection Chronic infection Unknown stage of infection Not applicable Hepatitis C Acute infection Chronic infection Unknown stage of infection Not applicable (This question is mandatory) When you report a case of hepatitis C, is it * Reinfection: new diagnosis of active hepatitis C (PCR-positive) in a patient with a history of cured hepatitis C (the cure, spontaneous or after treatment, must be documented by a negative PCR test at least 12 weeks after the end of treatment). An initial diagnosis A reinfection * Unknown (This question is mandatory) Is the patient HIV positive? yes no unknown 3. Consultation (This question is mandatory) Reason for STI screening/testing? Yes No Unknown The patient has symptoms/clinical signs that suggest he has an STI Yes No Unknown The patient's partner has an STI Yes No Unknown The patient has had risky sexual contact (unprotected sexual intercourse, broken condom, etc.) Yes No Unknown Pregnancy Yes No Unknown Routine screening / Blood tests Yes No Unknown Other reason Yes No Unknown (This question is mandatory) Reason for screening/testing? Yes No Unknown The patient has symptoms/clinical signs that suggest he has hepatitis Yes No Unknown The patient's partner has hepatitis Yes No Unknown The patient has had risky sexual contact (unprotected sexual intercourse, broken condom, etc.) Yes No Unknown The patient has shared drug paraphernalia (syringe, needle, snuff bag, etc.) Yes No Unknown Pregnancy Yes No Unknown Routine screening / Blood tests Yes No Unknown Other reason (e.g. accident with a needle, confirmation of a rapid test or self-test, etc.) Yes No Unknown Reason for screening/testing? If other, please specify 4. Risk factors (This question is mandatory) Does the patient use HIV Pre-exposure prophylaxis (PrEP)? Choose one of the following answers yes no unknown (This question is mandatory) Is the patient vaccinated against HPV? Choose one of the following answers yes no unknown (This question is mandatory) Has the patient been vaccinated against hepatitis B? Choose one of the following answers Yes, full schedule (3 doses) Yes, incomplete schedule (<3 doses) or number of doses unknown No Unknown (This question is mandatory) Has the patient ever used drugs? No, never Yes, less than 12 months ago Yes, 12 months or more ago I don't know If yes, what route of administration you patient use for their drug consumption? Select all that apply By injection By sniffing Through inhalation (with the exception of tobacco and cannabis) Orally Unknown route of administration Does the patient engage in chemsex? The use of drugs in a sexual context to increase the desire, duration or intensity of sexual intercourse Choose one of the following answers Yes No I don't know No answer Have you identified one or more care-related risk factors in the patient? Select all that apply Blood transfusion (especially before 1990 or outside Europe) Accident involving a needle stick at work Surgical, dental or invasive procedures in an environment where sterilisation precautions were uncertain – particularly abroad None of these factors were reported Other: (This question is mandatory) Have you discussed the possibility of notifying and screening your patient's sexual partners? Choose one of the following answers (This question is mandatory) Have you discussed the possibility of notifying and screening your patient's sexual partners/injection partners? Choose one of the following answers Submit Load unfinished survey Resume later Please confirm you want to clear your response? Exit and clear survey
