Perinatal Hepatitis B Questionnaire Form printable pdf download

Perinatal

Hepatitis B

PATIENT DEMOGRAPHICS

Name: (last, first): __________________________________________

Birth date: __ / __ / ____

Age: _____

Address (mailing): __________________________________________

Sex: Male Female Unk

Address (physical): __________________________________________

Ethnicity: Not Hispanic or Latino

City/State/Zip:

__________________________________________

Hispanic or Latino Unk

Phone (home):

______________ Phone(work/cell): _____________

White

Black/Afr. Amer.

Race:

Alternate contact:  Parent/Guardian  Spouse  Other

Native HI/Other PI

(Mark all

Name: ________________________________ Phone: __________________

Am. Ind/AK Native

that apply)

Asian

 Unk

INVESTIGATION SUMMARY

Investigation Start Date: __ /__ /____ Investigator: _______________________ Investigator phone: __________________

REPORT SOURCE/HEALTHCARE PROVIDER (HCP)

Report Source:  Laboratory Hospital  Private Provider

 Public Health Agency Other – Specify _______________________________

Reporter Name: ___________________________________________________ Reporter Phone: ________________________

Earliest date reported to LHD: __ /__ /____

Earliest date reported to State: __ /__ /____

CLINICAL

Primary HCP Name: _______________________________________

Primary HCP Phone: _____________________________________

N U

Clinical Findings

   Patient hospitalized for this illness

Y N U

   Is patient symptomatic?

If yes, hospital name:________________________________

Patient Chart #________________(if available)

Illness Onset date: ___ /___ /_____

   Jaundice

Admin Date: ___ / ___ / _____

Discharge Date: ___/___/____

   Did the patient die from this illness?

   Nausea

Place of Birth: ______________________________________

   Vomiting

Reason for testing (check all that apply)

 Symptoms of acute hepatitis

   Abdominal pain/right upper quadrant pain

 Screening of asymptomatic patient with reported risk factors

   Dark Urine

 Screening of asymptomatic patient with no risk factor, e.g. patient request

   Clay colored stool

 Evaluation of elevated liver enzymes

   Anorexia

 Follow-up testing for previous marker of viral hepatitis

   Malaise

 Blood/Organ donor screening

   Headache

 Unknown

   Fever

 Other, specify ______________________

Y N U

   Is patient pregnant? If yes, Due Date _______________________

Diagnosis date: ___ / ___ / _____

LABORATORY

(Please submit copies of ALL Labs associated with this illness to state health department)

ALT Result________

Upper Limits ______

Date: ___________

AST Result________

Upper Limits ______

Date: ___________

Y N U

   Total antibody to hepatitis A virus (total anti-HAV)

   Antibody to hepatitis C virus (anti-HCV)

   IgM antibody to hepatitis A virus (IgM anti-HAV)

   anti-HVC signal to cut-off ratio

   Hepatitis B surface antigen (HBsAg)

   Supplemental anti-HCV assay (e.g. RIBA)

   Hepatitis B ‘e’ antigen (HBeAg)

   HCV RNA (e.g. PCR)

   Total antibody to hepatitis B core antigen (Total anti-HBc)

   Antibody to hepatitis D virus (anti-HDV)

   IgM antibody to hepatitis B core antigen (IgM anti-HBc)

   Antibody to hepatitis E virus (anti-HEV)

   HBV DNA

  

EPIDEMIOLOGIC

 Confirmed

 Probable

Suspect

Not a Case

Unknown

Case Status:

 Hepatitis A, Acute

 Hepatitis B, Acute

 Hepatitis B, Chronic

Diagnosis:

X Perinatal Hepatitis B infection

 Hepatitis C, Acute

 Hepatitis C, Chronic (past or present)

 Hepatitis Delta

 Hepatitis E, Acute

y = Yes

N=No

U = Unknown NA=Not applicable

Division of STD, HIV and Hepatitis

rev 01-01-12

PERENITAL HBV

Perinatal Hepatitis B Questionnaire Form

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