Form Cdph 110a - Confidential Morbidity Report
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1
2State of California—Health and Human Services Agency
California Department of Public Health
CONFIDENTIAL MORBIDITY REPORT
PLEASE NOTE: Use this form for reporting all conditions except Tuberculosis and conditions reportable to DMV.
DISEASE BEING REPORTED
Patient Name - Last Name
First Name
MI
Ethnicity (check one)
Hispanic/Latino
Non-Hispanic/Non-Latino
Unknown
Race (check all that apply)
Home Address: Number, Street
Apt./Unit No.
African-American/Black
American Indian/Alaska Native
City
State
ZIP Code
Asian (check all that apply)
Asian Indian
Hmong
Thai
Home Telephone Number
Cell Telephone Number
Work Telephone Number
Cambodian
Japanese
Vietnamese
Chinese
Korean
Other (specify):
Email Address
Primary
English
Spanish
Filipino
Laotian
Language
Other: ______________
Pacific Islander (check all that apply)
Birth Date (mm/dd/yyyy)
Age
Gender
Native Hawaiian
Samoan
Years
M to F Transgender
Male
Guamanian
Other (specify): ________
Months
F to M Transgender
Female
White
Days
Other: ____________
Pregnant?
Est. Delivery Date (mm/dd/yyyy)
Country of Birth
Other (specify): _______________
Unknown
Yes
No
Unknown
Occupation or Job Title
Occupational or Exposure Setting (check all that apply):
Food Service
Day Care
Health Care
Correctional Facility
School
Other (specify): _______________________________________
Date of Onset (mm/dd/yyyy)
Date of First Specimen Collection (mm/dd/yyyy)
Date of Diagnosis (mm/dd/yyyy)
Date of Death (mm/dd/yyyy)
Reporting Health Care Provider
Reporting Health Care Facility
REPORT TO:
Alameda County Public Health Dept.
Address: Number, Street
Suite/Unit No.
Division of CD Control & Prevention
1000 Broadway, Suite 500
City
State
ZIP Code
Oakland, CA 94607
FAX (CD/STD): (510)268-2111
Telephone Number
Fax Number
FAX (TB): (510)273-3916
Phone: (510)267-3250 (bus. hours)
Submitted by
Date Submitted (mm/dd/yyyy)
(Obtain additional forms from your local health department.)
Laboratory Name
City
State
ZIP Code
SEXUALLY TRANSMITTED DISEASES (STDs)
Gender of Sex Partners
STD TREATMENT
Treated in office
Given prescription
Untreated
Treatment Began
(check all that apply)
Will treat
Drug(s), Dosage, Route
(mm/dd/yyyy)
Male
M to F Transgender
Unable to contact patient
Female
F to M Transgender
Patient refused treatment
Other: __________
Unknown
Referred to: ____________
If reporting Syphilis, Stage:
If reporting Chlamydia and/or Gonorrhea:
If reporting Pelvic Inflammatory Disease:
Syphilis Test Results
Titer
(check all that apply)
Specimen Source(s)
Symptoms?
Primary (lesion present)
RPR
Pos
Neg
_____
(check all that apply)
Yes
Gonococcal PID
Secondary
VDRL
Pos
Neg _____
Cervical
Early latent < 1 year
No
Chlamydial PID
Pharyngeal
FTA-ABS
Pos
Neg
Other/Unknown Etiology PID
Latent (unknown duration)
Unknown
Rectal
Late latent > 1 year
TP-PA
Pos
Neg
No, instructed patient to
Partner(s) Treated?
Urethral
refer partner(s) for
Late (tertiary)
EIA/CLIA
Pos
Neg
Yes, treated in this clinic
treatment
Urine
Congenital
Neg _____
Yes, Meds/Prescription given
CSF-VDRL
Pos
No, referred partner(s) to:
Vaginal
to patient for their partner(s)
Neurosyphilis?
Other: ____________________
Other: _________
Yes
No
Unknown
Yes, other: ______________
Unknown
VIRAL HEPATITIS
Pos
Neg
Pos
Neg
Diagnosis (check all that apply)
Is patient symptomatic?
Yes
No
Unknown
Hepatitis A
Suspected Exposure Type(s)
Hep A
anti-HAV IgM
Hep C
anti-HCV
Blood transfusion, dental or
Hepatitis B (acute)
ALT (SGPT)
medical procedure
RIBA
Upper
Hep B
HBsAg
Hepatitis B (chronic)
IV drug use
Result: _____ Limit: _____
HCV RNA
anti-HBc total
Hepatitis B (perinatal)
Other needle exposure
(e.g., PCR)
anti-HBc IgM
AST (SGOT)
Hepatitis C (acute)
Sexual contact
Upper
anti-HBs
Hep D
anti-HDV
Hepatitis C (chronic)
Household contact
Result: _____ Limit: _____
HBeAg
Perinatal
Hepatitis D
Hep E
anti-HEV
anti-HBe
Child care
Hepatitis E
Bilirubin result: ____________
HBV DNA: ___________
Other: _______________
Remarks:
CDPH 110a (7/11)
(for reporting all conditions except Tuberculosis and conditions reportable to DMV)
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