Hospitalization, Death, & Severe Respiratory Illness (Sri) Case Report Form Page 4

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…
…
…
…
…
…
Chronic Pulmonary disease
Yes
No
Unknown
Pregnant
Yes
No
Unknown
(or <6wks postpartum)
…
…
…
weeks of gestation_____ or
Asthma
Yes
No
Unknown
If yes,
…
…
…
trimester:_________ or
Chronic heart disease
Yes
No
Unknown
…
…
…
weeks postpartum_______
Chronic Liver disease
Yes
No
Unknown
Diabetes
…
…
…
Yes
No
Unknown
Other condition/risk, specify:
Kidney disease
…
…
…
Yes
No
Unknown
Weight:________
… Kgs … Pounds
Immunodeficiency
…
…
…
Yes
No
Unknown
Height: ________
…cm …inches
Anemia or Hemoglobinopathy
…
…
…
Yes
No
Unknown
Obesity (as per chart)
…
…
…
Yes
No
Unknown
Chronic Neurological disease
…
…
…
Yes
No
Unknown
Current smoking
…
Yes
…
No
…
Unknown
SECTION 7: LABORATORY TESTING
Outbreak Number: _____________________________________
Date Specimen
P/T Lab
Date Test
Laboratory
Specimen
Test
Test
Collected
Specimen
Performed
Performing
Source
Method
Result
(dd/mm/yyyy)
Number
(dd/mm/yyyy)
Test
*Recommended specimens for optimal investigation of influenza include: nasopharyngeal swab; nasal swab; bronchoalveolar lavage
(BAL); serum (as per consultation with NML)
SECTION 8: EXPOSURES
Is the patient:
… A health care worker exposed to SRI patient(s) under investigation
… Exposed to a person who is part of a cluster of human swine influenza or SRI (Please describe location of cluster):
…
Acute care facility
…
Long term care facility
…
School-based
…
Community-based
… A laboratory worker working directly with emerging or re-emerging pathogens
… In contact with any of the following animals within 7 days after symptom onset:
…
swine
…
poultry
…
other (e.g. mink, ferrets): __________________________
In the 10 days prior to symptom onset, had the patient travelled outside of NL:
… Yes …No …Unknown
If yes, please specify location: _________________________________________________________________
Date of arrival (dd/mm/yyyy): ____/____/________
Date of departure (dd/mm/yyyy): ____/____/________
SECTION 9: SUMMARY OF CLOSE CONTACTS* IN THE 7 DAYS PRIOR TO SYMPTOM ONSET
… Household contacts: _____
… Workplace contacts: _____
… Other close contacts: ____(i.e. social)
Total # contacts: ____
*Close contact: having cared for, lived with, or had direct contact with respiratory
secretions or body fluids of a probable or confirmed case of human swine influenza.
Revised November 12, 2009
16

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