Form Dhhs 3445 - Special Serology printable pdf download

DO NOT WRITE IN THIS

N.C. Department of Health and Human Services

[1]

1. Last Name

First Name

State Laboratory of Public Health

SPACE

4312 District Drive • P.O. Box 28047

2. Patient Number

Raleigh, NC 27611-8047

LABORATORY NUMBER

4. Date of Birth

3. Address

...........................................................

Zip

Month

Day

Year

Code



5. Race

1. White

2. Black

3. American Indian

4. Asian

PLEASE GIVE ALL





INFORMATION REQUESTED

5. Native Hawaiian/Paciﬁ c Islander

6. Unknown



6. Hispanic or Latino Origin?

1. Yes

2. No

3. Unknown

Special Serology



7. Sex

1. Male

2. Female

8. Co. of Residence



9. Medicaid Client

Yes

—



If yes, enter #

[4] SPECIMEN(S) SUBMITTED:

[5] DATE COLLECTED:

[2] Federal Tax No.: ________________________________________



ACUTE SERUM

within 7 days of onset

Send Report To:



CONVALESCENT SERUM

______________________________________________________

CSF



______________________________________________________

________________________________Zip Code: ______________

URINE



[3] Provider Name: _________________________________________ [6] ONSET DATE:

[7] Dx Code/ICD-10:

NPI:

[8]

PATIENT SIGNS AND SYMPTOMS

GENITAL

RASH

RESPIRATORY

CNS

CARDIOVASCULAR

GENERAL

  Vesicles

 Macular

 Cough

 Seizures

 Chest Pain

 Fever to _____ °

  PID

 Papular

 Pneumonia

 Meningitis

 Pericarditis

 Headache

  Cervicitis

 Vesicular

 Bronchitis

 Encephalitis

 Myocarditis

 Fatigue

  Urethritis

 Petechial

 Croup

 Nuchal rigidity

 Pleurodynia

 Sore Throat

  Hysterectomy

 Focal

 Pharyngitis

 Paralysis

GASTROINTESTINAL

 Jaundice

  Mucopurulent discharge

 Hemorrhagic

 Nausea/vomiting

 Conjunctivitis



  Atypical Lesion

 Diarrhea

 Arthralgia/Myalgia



Recent Vaccination History:

Travel History:

INFECTIOUS AGENT(S) SUSPECTED AND TEST(S) REQUESTED

[9]

Serologic Diagnostic Panels Available:

Single Agent Diagnostic Tests:

(Check one or more boxes, as needed)

  Arboviral Panel (Eastern Equine Encephalitis, Western

 Q Fever

Equine Encephalitis, St. Louis Encephalitis, La Crosse

 Zika

Encephalitis and West Nile)

 Chikungunya

  Rickettsia Panel (Rickettsia rickettsii, Rickettsia typhi,

Ehrlichia species)

 Other: __________________________________________

_______________________________________________

 Exanthems:

  Measles, Rubella

 Prior approval/consultation received from:

  Varicella Zoster

_______________________________________________

  Mumps

(All suspect cases should be called to Communicable Disease prior to

 Please forward specimen to CDC for testing. (Attach a

submission of specimen to State Lab. Communicable Disease can be

completed CDC 50.34 DASH form.)

reached at 919-733-3419.)

FOR LABORATORY USE ONLY

 Unsatisfactory Specimen:

  No name on specimen

 Specimen broken/leaked

  Name on specimen/form do not match

 No specimen received

 Other __________________________________________

Comments:

DHHS 3445 (Revised 05/2016)

Laboratory (Review 05/2019)

SEE REVERSE SIDE FOR INSTRUCTIONS AND FURTHER INFORMATION

Form Dhhs 3445 - Special Serology

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