Invasive Group A Streptococcal Disease (Streptococcus Pyogenes) Case Report Form
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1Unique ID: _______________
Invasive Group A Streptococcal Disease (Streptococcus pyogenes)
Case Report Form
Date of Initial Report: ____/____/_____ (dd/mm/yyyy)
Date of Update: ____/____/_______ (dd/mm/yyyy)
Person Reporting: ____________________________
Phone: (
) ____ - _________ ext: ____
Jurisdiction Reporting: _________________________________
PATIENT INFORMATION
Last name: ________________________________ First name: _____________________________
Birthdate
: ____/____/_______
or Age: ______ years or _______ months
(dd/mm/yyyy)
Sex:
Male
Female
Unknown
Ethnicity:
Non-Aboriginal
First Nations
Inuit
Metis
Other: ____________________
Unknown
CLINICAL PRESENTATION and UNDERLYING CONDITIONS/ILLNESSES
Date of onset of symptoms
: ____/____/_______
(dd/mm/yyyy)
Admitted to hospital?
Yes
if yes,
Admission date
: ____/____/_______
(dd/mm/yyyy)
No
Discharge date
: ____/____/_______ or
Not discharged
(dd/mm/yyyy)
Unknown
Admitted to ICU?
Yes
No
Unknown
Outcome:
Survived (recovered)
Died
if yes, Date of death
: ____/____/_______
(dd/mm/yyyy)
Survived with long-term sequelae, please specify: __________________________________
Underlying Conditions and/or
Syndrome
Yes
No
Unk
Yes
No
Unk
Risk factors
Meningitis
Alcohol abuse
Septicaemia
Homelessness
Bacteremia
Injection drug use
Cellulitis
Chronic lung disease
Pneumonia
Diabetes
Necrotizing fasciitis
Immunodeficiency disease
Myositis
Immunosuppressive therapy
Gangrene
Post-partum
Toxic shock syndrome
Surgery/surgical wound
Septic arthritis
Trauma or burn
Other, specify: ___________________
Skin infection or dermatological condition
Varicella (if yes, date:
/
/
)
dd/mm/yyyy
Contact with person with iGAS
Other, specify: ______________________
Other, specify: ______________________
LABORATORY INFORMATION
Specimen source:
Blood
CSF
Joint fluid
Tissue (please specify): _____________________
Other, specify: _______________________________________
Serotyping:
Emm type: _________ T type: _____________ Serum opacity factor (SOF): _____________
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