State Form 35212 - Virology
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VIROLOGY
Indiana State Department of Health Laboratories
550 W. 16th Street, Suite B
State Form 35212 (R6/9-09)
Indianapolis, IN 46202
CLIA Certified Laboratory #15D0662599
(317) 921-5500
Use a separate form for each specimen.
Complete form entirely. Specimens without a name will not be analyzed.
Section 1. Patient Demographics
/
/
MI
Last Name
First Name
Date of Birth
ZIP Code
Number & Street Address
City
State
-
-
County of Residence
Telephone Number
Race:
Ethnicity:
Asian
White
Hispanic or Latino
Not Hispanic or Latino
Unknown
Black or African American
Multiracial
Sex:
American Indian or Alaska Native
Other
Native Hawaiian or Other Pacific Islander
Male
Female
Unknown
Unknown
-
-
Facility Telephone Number
Name of
Employer
School
Care Facility
Institution
Occupation
Other (specify)
Institution Type
Prison
Nursing Home
Institution Resident ?
Yes
No
/
/
Hospitalized?
Yes
No Location
Date Hospitalized
/
/
Deceased?
Yes
No
Date of Death
Section 2. Clinical Information
/
/
/
/
Date of Collection
Date of Illness Onset
Specimen Information:
Tissue
Swab
(Anatomical Source)
Stool
(Anatomical Source)
Isolate
Fluid
Other: _________________________
(Anatomical Source)
(Anatomical Source)
Clinical Diagnosis
Asymptomatic
Symptomatic (If patient is symptomatic, please check all signs/symptoms that apply)
State of Illness
CNS
Respiratory
Rash
Gastrointestinal
Miscellaneous
General Symptoms
.
Encephalitis
Maculopapular
Upper Resp. Inf.
Vomiting
Parotitis
Fever
° F
Meningitis
Papular
Lower Resp. Inf.
Diarrhea
Headache
Ocular
Pneumonia
Hemorrhagic
Sore Throat
Cardiovascular
Conjunctivitis
Heart Inflammation
ARDS
Vesicular
Cough
Photophobia
Petechial
Other Symptoms
(please specify)
Pregnant ?
Yes
No
Yes
No
Immunocompromised?
Section 3. Virus Suspected
Herpes Simplex
Adenovirus
Enterovirus
Measles
Influenza
Community-Acquired Pneumonia
Mumps
Parainfluenza
Other
Respiratory Syncytial Virus
Varicella
Section 4. ISDH Lab Use
Place Label here
For ISDH Lab. Use ONLY
/
/
Date Received
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