Maryland Confidential Morbidity Report (Dhmh 1140)
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1MARYLAND CONFIDENTIAL MORBIDITY REPORT (DHMH 1140)
STATE DATA BASE NUMBER
(For use by physicians and other health care providers, but not laboratories. Laboratories should use forms DHMH 1281 & DHMH 4492.)
SEND TO YOUR LOCAL HEALTH DEPARTMENT
(First)
(M.I.)
Patient’s Name (Last)
Sex at Birth
Date of Birth Age
Male
Female
Current Gender
Female
Male
City
State
Zip
Patient’s Address
M to F Transgender
F to M Transgender
Home Telephone
Cellphone
Work Telephone
County of Residence
Other
Race:
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
American Indian or Alaskan Native
Not Employed
Food Service Worker
Occupation or Contact with Vulnerable Persons
Asian
Black or African American
Other (Specify):
Daycare
Parent of Daycare Child
Hawaiian or Pacific Islander
Health Care Worker
White
Workplace, School, Child Care Facility, Etc.
Unknown
(Include Name, Address, Zipcode)
Other
:
(specify)
Date of Onset Patient Notified of this Condition
Pertinent Clinical Information/Comments
Disease or Condition
Yes
No
Patient Hospitalized
Yes
No
Patient Died of This Illness
Date
Hospital
No Da te
Yes
Condition Acquired in Maryland
Additional Lab Results
Patient Pregnant
(Specimen – Test – Result – Date – Name
of Lab) Please attach copies of lab reports whenever possible.
Not applicable
Yes
Unknown
Yes
No
Unknown
No
If no,
Interstate
International
If yes, Due date (mm/dd/yyyy)
Suspected Source
Weeks Pregnant
Laboratory Results
POS NEG
DATE
POS NEG
DATE
HAV Antibody Total
HBV surface Antibody
HCV Genotype
DATE
HAV Antibody IgM
ALT (SGPT) Level
HBV DNA
DATE
ALT–Lab Normal Range
HBV surface Antigen
HCV Antibody RIBA
TO
AST (SGOT) Level
HBV e Antigen
HCV RNA (e.g. by PCR)
DATE
HCV Antibody ELISA
HBV core Antibody Total
AST–Lab Normal Range
TO
HCV ELISA s/co Ratio
HBV core Antibody IgM
Name of Lab
Risk Exposure
(Select all that apply)
HIV Lab Tests
Result
Date
Complete for HIV/AIDS or STI
HIV Diagnostic (Specify)
Sex with Male
CD4+ T-cells
Sex with Female
HIV Viral Load
Sex Partner has
HIV or AIDS
HIV Genotype (Resistance)
Name of Testing Lab
Sex Partner Injects Drugs
Gonorrhea Site(s)
Chlamydia Site(s)
Syphilis Stage
Syphilis Symptoms
Other STI (specify)
Sex Partner is Male that
Cervical
Cervical
has Sex with Males
Lesion
Primary
Urethral
Urethral
Injection Drug Use
Secondary
Palmar/Plantar Rash
Rectal
Rectal
Perinatal Exposure of
Early Latent (<1 yr)
Condylomata Lata
Pharyngeal
Pharyngeal
Newborn
Neurologic
Congenital
Ophthalmia Neonatorum
PID
Other Exposure (specify)
Other Stage (specify)
Other (specify)
PID
Other (specify)
Other (specify)
Specify STI Lab Test (e.g. RPR Titer, FTA-TPPA, Darkfield, Smear, Culture, NAAT, EIA, VDRL-CSF)
STI Treatment Given
(Specify date – drug – dosage below)
No Treatment Given
DATE
TEST
RESULT
DATE
DRUG
DOSAGE
Did you provide treatment for any of this patient's partners? (Check all that apply)
Yes, I gave medication for __ (#) partner(s)
Yes, I wrote a prescription for __(#) partner(s)
Yes, I saw the sex partner(s) in my office
Tuberculosis (Suspect or Confirmed)
Non TB: Atypical (Specify)
POS QFT
Major Site:
POS
AFB Smear
POS
Pulmonary
Culture
TST
mm
QFT
Extrapulmonary
NEG
NEG
AFB Smear
NEG
Culture
Site:
Fever
Weight Loss
Fatigue
Symptoms:
Hemoptysis
Cough >3 Weeks
Abnormal Chest X-ray
Date of Report
Provider Telephone No.
Provider Name
Check here
if completed
by the
Facility/Organization (Name and Address)
Local Health
Department
NOTES: Your local health department may contact you following this initial report to request additional disease-specific information.
DHMH 1140
To print blank report forms or get more information about reporting, go to
Revised 07/2015
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