Dcls Arboviral Infection Case Report Form
ADVERTISEMENT
1Attachment 2.D
ARBOVIRAL INFECTION CASE REPORT FORM
PATIENT INFORMATION
Last Name__________________________
First Name _______________________
County_____________________
Address___________________________________
City ___________________
Zipcode__________
State_______
Telephone-H (____)_____-_______
W (____)_____-_______
Date of Birth_____/_____/_____
Age_______
Occupation:_________________________
Race:
White
Black
Am. Indian/Alaskan
Asian
Other
Ethnicity:
Hispanic
Non-Hispanic
Unknown
Sex:
Male
Female
Pregnant:
Yes
No
Unknown
Breast Feeding:
Yes
No
Unknown
CLINICAL INFORMATION
Hospitalized?
Yes
No
Hospital Name___________________________________________________
Street Address____________________________
City_______________________ State_____ Zip __________
Medical record # ____________________
Date of admission____/____/____
Date of discharge/transfer____/_____/____
Date of first symptoms____/____/____
Date of first neurologic symptoms____/____/____
Current Diagnosis:
encephalitis
meningitis
myelitis
fever
other_____________________
Initial Diagnosis:
encephalitis
meningitis
myelitis
fever
other_____________________
Fever (> 38EC or 100EF)
Yes
No
Unknown
Altered mental status
Yes
No
Unknown
Headache
Yes
No
Unknown
Stiff neck/Meningeal signs
Yes
No
Unknown
Seizures
Yes
No
Unknown
Muscle weakness
Yes
No
Unknown
Altered immune status
Yes
No
Unknown
Previous Flavirus vaccination
Yes
No
Unknown
Rash
Yes
No
Unknown
If yes, describe__________________________________________
Other neurologic signs
Yes
No
Unknown
If yes, describe__________________________________________
Other symptoms (current or 1 month before onset)______________________________________________________________
Outcome
Recovered
Died
Unknown
If patient died, date of death _____/_____/_____
LABORATORY INFORMATION / TEST RESULTS
CSF (specify units)
Date _____/_____/_____
Abnormal?
Yes
No
Unknown
Glu ________
Prot ________
RBC ________
WBC ________
Diff: Segs _______%
Lymphs______%
Gram stain ____________________________
Culture _____________________________
CBC (specify units) Date _____/_____/_____
WBC ________
Diff: Segs ______%
Lymphs _____%
MRI Date _____/_____/_____
Results _____________________________________________________________
CT Date _____/_____/_____
Results _____________________________________________________________
EEG Date _____/_____/_____
Results _____________________________________________________________
Microbiology / serology
Results _____________________________________________________________
CURRENT TREATMENT
Type:
Date started:
(antiviral or antibacterial)
_________________________________________
_____/_____/_____
RISK FACTOR INFORMATION (during 2 weeks before onset)
Location
Dates
Travel outside USA?
Yes
No
Unk
_________________________
________________
Travel outside Virginia?
Yes
No
Unk
_________________________
________________
Travel outside county of residence?
Yes
No
Unk
_________________________
________________
Occupational exposure (lab or farm)?
Yes
No
Unk
_________________________
________________
Animal/bird contact?
Yes
No
Unk
_________________________
________________
If yes specify species: _______________________________
Blood or organ donor?
Yes
No
Unk If yes, contact the VDH Office of Epidemiology immediately
Blood transfusion or organ transplant?
Yes
No
Unk If yes, contact the VDH Office of Epidemiology immediately
(during 1 month before onset)
SPECIMENS BEING SUBMITTED TO LAB FOR TESTING
Has the patient previously tested positive for
WNV
SLE
EEE
LAC.
What antibody was detected?
IgM
IgG
What laboratory tested the specimen? ______________________________________
Name of Lab _____________________
CSF
Yes
No
If yes, date collected _____/_____/_____
Initial
Repeat
If no, was a lumbar puncture performed?
Yes
No
Name of Lab _____________________
Serum
Yes
No
If yes, date collected _____/_____/_____
Initial
Repeat
Name of Lab _____________________
Other ________________
Date collected _____/_____/_____
Initial
Repeat
PHYSICIAN
Last name _____________________________
First name _____________________________
Work address_______________________________
City _____________________
State______
Zip Code __________
Telephone (______) _______-__________
Pager (______) _______-_________
SUBMITTER
Name _______________________________________________
Address _____________________________________________
_____________________________________________
_____________________________________________
Phone (______) _______-__________
Date of Report: _____/_____/_____
Form ENC-1
Revised April 2005
Virginia Arbovirus Plan, 2005
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business