Varicella Case Report Form - Connecticut Page 2

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Did the patient develop any complications that were diagnosed by a healthcare provider? [Check all that apply]
Yes
No
Unknown
Skin/soft tissue infection
Cerebellitis/ataxia
Encephalitis
Dehydration/hypovolemia
Hemorrhagic condition
Pneumonia (diagnosed by
X-ray
MD
unknown)
Meningitis
Other complications (Specify: ____________________________)
Was the patient treated with antivirals?
Yes, name: ___________________________ Started on ______/______/_________
No or N/A
Unknown
Is the patient immunocompromised due to a medical condition or treatment?
Yes, specify ____________________________________________________________
No
Unknown
Does the patient have any co-morbid medical conditions?
Yes, specify
________________________
No
Unknown
Did the patient die from varicella or complications (including secondary infection) associated with varicella?
No
Unknown
Yes, date of death: ______/______/_________
Autopsy performed?
Yes
No
Unknown
Cause of death: _____________________________________________________
Was the patient hospitalized?
No
Unknown
Yes, name of hospital _____________________________________________________
Admit date: ______/______/_________ Discharge date: ______/______/_________
Primary reason for hospitalization:
Severe varicella presentation
Unknown
Varicella-related complication
Observation
Administration of IV treatment
Isolation
Non-varicella hospitalization with coincident varicella
Other _________________________________________________
Return form to: Connecticut Department of Public Health
Immunization Program
410 Capitol Ave, MS #11MUN
Hartford, CT 06134
or fax form to (860) 509-7945
Questions? Call (860) 509-7929
DPH use only
CTEDSS ID: ___________________
Case status:
Confirmed
Probable
Suspect
Not a case
Epi-linked to another case?
Yes, case ID ___________________
No
Unknown
Outbreak linked?
Yes, name of outbreak: ______________________________________
No
Unknown

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