Acute Rheumatic Fever (Arf) Form - Notification Form For Clinicians - Queensland Government
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1
2Acute Rheumatic Fever
(ARF)
Notification form for clinicians
ARF is a notifiable condition. Report all confirmed and suspected cases.
Please fax form to your nearest Public Health Unit
(see
for numbers)
PHU will inform the ARF/RHD Register & Control Program, Queensland
PATIENT
NOTIFYING DOCTOR
4
Family name
______________________________________
Date
___/___/____
Given name
______________________________________
Name
_______________________________________
Alias
____________________________________________
Hospital/Clinic
________________________________
Hosp/Clinic No
____________________________________
Address
_____________________________________
Address: permanent
_______________________________
Suburb/Town
_________________
Postcode
_______
Suburb/Town
_____________________
Postcode
______
Telephone
___________________________________
Address: temporary
________________________________
Health Service Provider patient usually
attends:___
Suburb/Town
_____________________
Postcode
______
______________________________________________________
Telephone
________________________________________
Date of birth
_____/_____/______
Sex
Male
Female
Signature
________________________________
_______________
Aboriginal
Torres Strait Islander
Aboriginal and Torres Strait Islander
Maori
Pacific Islander
other
______________
Unknown
CURRENT ARF EPISODE
Initial ARF
Recurrent ARF
Don’t know
4
Earliest date patient exhibited symptoms of ARF:
___/___/____
Hospitalisation: from
___/___/____
to
___/___/____
Name of hospital:
________________________________
1
1
MAJOR MANIFESTATIONS
(tick all that apply)
MINOR MANIFESTATIONS
(tick all that apply)
2
2
Poly-arthralgia (high risk groups)
Poly-arthralgia (low risk groups)
2
2
Aseptic mono-arthritis (high risk groups)
Aseptic mono-arthritis (low risk groups)
2
Poly-arthritis
Erythema marginatum
Mono-arthralgia (high risk groups)
o
o
Carditis
Sydenham’s chorea
Fever (≥38
C):
_____
C
Sub-clinical carditis
Subcutaneous nodules
Prolonged P-R interval on ECG
Elevated ESR (≥30 mm/hr):
______
mm/hr
_ _/__/__
CRP (≥30 mg/L):
______
mg/L
__/__/__
EVIDENCE OF PRECEDING GROUP A STREP (GAS) INFECTION
st
4
Date 1
specimen taken
3
Elevated ASOT
:
________IU/mL
___/___/___
________IU/mL
___/___/___
3
Elevated Anti-DNaseB
:
________IU/mL
___/___/___
________IU/mL
___/___/___
Positive throat culture
___/___/___
1, 2, 3, 4,
For
see
NOTES
_______________________________________________________________________
____________________________________________________________________________
_______________________________
date
name
Entered on NoCS
_______________________________
Entered on RHD database
V6 January 2013
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