Hospitalization, Death, & Severe Respiratory Illness (Sri) Case Report Form (Page 3 of 4) in pdf

… SRI Case

… SRI Death

… pH1N1 Hospitalization

… pH1N1 Death

(lab-confirmed)

SECTION 2: ADMINISTRATIVE INFORMATION

Date of initial report (dd/mm/yyyy): _____/_____/_________

… Initial Report

Report Status

… Update

Date of this update (dd/mm/yyyy): ______/_____/_________

Name/affiliation of person making report:

Reporting Province: ____________________________

________________________________________________

Reporting RHA: __________________________

Reporting contact phone no: (____) ____ - ______ext____

Province where case resides:_____________________

SECTION 3: PATIENT INFORMATION

Aboriginal … Yes

… No … Unknown

Gender: … Male … Female … Unknown

If Aboriginal, what is their ethnicity

Age: ____ years, … Age unknown

… Inuit

… Innu

If under 2 years of age, specify ____ months

… Métis

… First Nations (FN):

Occupation: _____________________________

If FN, does this person live primarily on reserve? …Yes …No …Unknown

If FN, is this person a ‘Registered Indian’? … Yes … No … Unknown

Is patient from:

Isolated Community …Yes …No …Unknown

Remote Community … Yes

… No … Unknown

(no year round road access)

(•200km or •4hrs from community with acute care

hospital, but where year-round road access avail).

SECTION 4: CLINICAL INFORMATION

Symptoms (check all that apply):

Date of onset of first symptom(s) (dd/mm/yyyy): ___/____/_______

… fever

… prostration

… diarrhea

… altered level of consciousness

… cough

… rhinorrhea or nasal congestion

… nausea

… nose bleed

… sore throat

… sneezing

… vomiting

… encephalitis

… arthralgia

… shortness of breath

… conjunctivitis

… other, specify:

… myalgia

… sputum production

… headache

___________________________

… malaise

… chest pain

… seizures

Was this case hospitalized:

… Yes

… No … Unknown

Date of initial admission (dd/mm/yyyy): ___/____/____

Date of final discharge (dd/mm/yyyy): ____/____/_____

Course of Illness/Severity:

Admitted to ICU?

… Yes

… No … Unknown

On oxygen therapy during any of the hospital stays?

… Yes

… No … Unknown

Ventilated during any of the hospital stays?

… Yes

… No … Unknown

Pneumonia diagnosed by chest x-ray or CT scan?

… Yes

… No … Unknown

Diagnosed with Acute Respiratory Distress Syndrome (ARDS) … Yes

… No … Unknown

Disposition at time of report:

… Stable … Deteriorating … Recovering

… Died (indicate date/cause below) … Unknown

If patient died,

Date of death (dd/mm/yyyy): ___/___/________ Cause of death (specify): ________________

SECTION 5: MEDICAL AND VACCINE HISTORY

Treatment: Is patient taking prescribed antivirals?

… Yes

… No … Unknown

If yes, Specify name: ___________________

Start date (dd/mm/yyyy): ____/____/_______End date (dd/mm/yyyy): ____/____/________

Did patient receive this year’s seasonal human influenza vaccine?

… Yes

… No … Unknown

If yes, date of vaccination (dd/mm/yyyy): ___/___/________

SECTION 6: UNDERLYING CONDITIONS and RISK FACTORS

Revised November 12, 2009

Hospitalization, Death, & Severe Respiratory Illness (Sri) Case Report Form Page 3

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