Toggle navigation Load unfinished survey Resume later Exit and clear survey 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. SGP_STI_2024 Registration covers each new episode of the following 5 STIs (sexually transmitted infections), after lab confirmation (ex. for genital warts and genital herpes). 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 2037-12-31 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 Does the patient has access to OMNIO/BIM statute, urgent medical aid, CPAS/OCMW or other financial help? Yes No No answer 2. Diagnostic (This question is mandatory) Diagnosis STI: first infection reinfection Not applicable Chlamydia trachomatis 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 (reinfection = an infection with an STI in a patient with a history of previous infection with the same STI, unrelated to the current episode) (This question is mandatory) Is the patient HIV positive? Choose one of the following answers yes no unknown 3. Consultation (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) Reason for screening/testing? Yes Uncertain No Patient has STI symptom(s) Yes Uncertain No A partner of the patient has an STI Yes Uncertain No Patient at risk in the last 3 months (condom breakage, condom failure) Yes Uncertain No Other reason (ex: pregnancy) Yes Uncertain No Reason for screening/testing? If other, please specify 4. Risk factors (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 (This question is mandatory) Sexual orientation Choose one of the following answers homosexual heterosexual bisexual unknown (This question is mandatory) Number of sex partners within the last 6 months? Choose one of the following answers <3 >=3 unknown (This question is mandatory) Does the patient generally use condoms during alternating sexual contacts? Choose one of the following answers yes no, but the patient is in an exclusive relationship/has exclusive partners no, but the patient takes PrEP and is regularly followed up no, but the patient is undetectable (HIV) and is regularly followed up at a reference centre no, for other reasons unknown (This question is mandatory) Does the patient use 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) Have you discussed the possibility of notifying and treating your patient's sexual partners? Yes No Submit Load unfinished survey Resume later Please confirm you want to clear your response? Exit and clear survey ×
