Form Cdc - Viral Hepatitis Case Report
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6CDC
U.S. DEPARTMENT OF
VIRAL HEPATITIS CASE REPORT
HEALTH & HUMAN SERVICES
Centers for Disease Control
PUBLIC HEALTH SERVICE
and Prevention
Hepatitis Branch, (G37)
Atlanta, Georgia 30333
The following questions should be asked for every case of viral hepatitis
Prefix: (Mr. Mrs. Miss Ms. etc) ______
Last: ______________________________ First: _________________________
Middle: _________________
Preferred Name (nickname): _________________________________
Maiden: _________________________________________________________
Address: Street: ________________________________________________________________________________________________________________
City: ________________________________________________
Phone: (
) -
Zip Code: ___ ___ ___ ___ ___ -- ___ ___ ___ ___
SSN # (optional) ___ ___ __ - ___ ___ - ___ ___ ___ ___
Only data from lower portion of form will be transmitted to CDC
State: _______________
County: ______________________________________________ Date of Public Health Report__ __ / __ __ / __ __ __ __
Was this record submitted to CDC through the NETSS system? Yes
No
If yes, please enter NETSS ID NO.
If no, please enter STATE CASE NO.
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DEMOGRAPHIC INFORMA
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TION
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RACE (check all that apply):
ETHNICITY:
Amer Indian or Alaska Native
Black or African American
White
Hispanic ....................
Asian
Native Hawaiian or Pacific Islander
Other Race, specify: ___________
Non-hispanic .............
PLACE OF BIRTH:
USA
Other:____________
SEX:
Male
Female
Unk
Other/Unknown .........
M M D D Y Y Y Y
DATE OF BIRTH: __ __ / __ __ / __ __ __ __
AGE: ___ ___ (years)
( 00= <1yr
, 99= Unk )
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CLINICAL & DIAGNOSTIC DATA
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1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8
REASON FOR TESTING: (Check all that apply)
Symptoms of acute hepatitis
Evaluation of elevated liver enzymes
Screening of asymptomatic patient with reported risk factors
Blood / organ donor screening
Screening of asymptomatic patient with no risk factors (e.g., patient requested )
Follow-up testing for previous marker of viral hepatitis
Prenatal screening
Unknown
Other: specify: ____________
CLINICAL DATA:
DIAGNOSTIC TESTS: CHECK ALL THAT APPLY
Pos
Neg
Unk
M M
D D
Y Y Y Y
__ __ / __ __ / __ __ __ __
Diagnosis date:
•
Total antibody to hepatitis A virus [total anti-HAV] ................
Yes
No Unk
•
IgM antibody to hepatitis A virus [IgM anti-HAV] .....................
Is patient symptomatic? ...........................................
•
Hepatitis B surface antigen [HBsAg]
.............................................
if yes, onset date:
M M
D D
Y Y Y Y
__ __ / __ __ / __ __ __ __
•
Total antibody to hepatitis B core antigen [total anti-HBc] .....
Was the patient
•
•
IgM antibody to hepatitis B core antigen [IgM anti-HBc] .........
Jaundiced? ...............................................................
•
•
Hospitalized for hepatitis? ....................................
Antibody to hepatitis C virus [anti-HCV] ...................................
-
Was the patient pregnant ? .......................................
anti-HCV signal to cut-off ratio __________
M M D D
Y Y Y Y
•
due date :
__ __ / __ __ / __ __ __ __
Supplemental anti-HCV assay [e.g., RIBA] ..............................
•
Did the patient die from hepatitis? ..........................
HCV RNA [e.g., PCR] .....................................................................
•
M M D D
Y Y Y Y
__ __ / __ __ / __ __ __ __
Date of death:
•
Antibody to hepatitis D virus [anti-HDV] ...................................
•
Antibody to hepatitis E virus [anti-HEV] ...................................
•
LIVER ENZYME LEVELS AT TIME OF DIAGNOSIS
If this case has a diagnosis of hepatitis A that has not been
Yes
No
Unk
•
serologically confirmed, is there an epidemiologic link between
ALT [SGPT] Result ______
Upper limit normal_______
•
this patient and a laboratory-confirmed hepatitis A case? ............
AST [SGOT] Result ______
Upper limit normal_______
•
M M D D Y Y Y Y
Date of ALT result
__ __ / __ __ / __ __ __ __
•
Date of AST result
M M D D Y Y Y Y
__ __ / __ __ / __ __ __ __
DIAGNOSIS: (Check all that apply)
Acute hepatitis A
Acute hepatitis B
Chronic HBV infection
Perinatal HBV infection
Hepatitis Delta (co- or super-infection)
Acute hepatitis C
HCV infection (chronic or resolved)
Acute hepatitis E
Acute non-ABCD hepatitis
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