Form Epid 200 - Kentucky Reportable Disease Form

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Kentucky Reportable Disease Form
Department for Public Health
Division of Epidemiology and Health Planning
275 East Main St., Mailstop HS2E-A
Frankfort, KY 40621-0001
EPID 200 – 6/2016
Disease Name ______________________________
Fax or Mail the Completed Form to the Local Health Department
DEMOGRAPHIC DATA
Patient’s Last Name
First
M.I.
Date of Birth
Age
Gender
M
F
Unk.
/
/
Address
City
State
ZIP Code
County of Residence
Phone Number
Patient ID Number
Ethnic Origin
Race
Hisp.
Non-Hisp.
W
B
A/PI
Am. Ind.
Other
DISEASE INFORMATION
Disease/Organism
Date of Onset
Date of Diagnosis
/
/
/
/
List Symptoms/Comments
Highest Temperature
Days of Diarrhea
Hospitalized?
Admission Date
Discharge Date
Died?
Date of Death
Yes
No
Yes
No
Unk.
/
/
/
/
/
/
Hospital Name:
Is Patient Pregnant?
Yes
No If yes, Due Date (EDC):
/
/
School/Daycare Associated?
Yes
No
Outbreak Associated?
Yes
No
Food Handler?
Yes
No
Name of School/Daycare:
Person or Agency Completing form:
Attending Physician:
Name:
Agency:
Name:
Address:
Address:
Phone:
Date of Report:
/
/
Phone:
LABORATORY INFORMATION
Date
Name or Type of Test
Name of Laboratory
Specimen Source
Results
ADDITIONAL INFORMATION FOR SEXUALLY TRANSMITTED DISEASES ONLY
Disease:
Stage
Disease:
Site: (Check all that apply)
Resistance:
Gonorrhea
Primary (lesion)
Secondary (symptoms)
Genital, uncomplicated
Ophthalmic
Penicillin
Syphilis
Chlamydia
Early Latent
Late Latent
Pharyngeal
PID/Acute
Tetracycline
Chancroid
Congenital
Other
Anorectal
Salpingitis
Other ___________
Other___________________
Date of Spec.
Laboratory Name
Type of Test
Results
Treatment Date
Medication
Dose
Collection
If syphilis, was previous treatment given for this infection?
Yes
No
If yes, give approximate date and place______________________________________________________________________________

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