Form Cdc - Viral Hepatitis Case Report Page 2
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6DRAFT COPY
Patient History- Acute Hepatitis A
NETSS ID NO.
STATE CASE NO. _________________________________________
During the 2-6 weeks prior to onset of symptoms-
Yes
No
Unk
Was the patient a contact of a person with confirmed or suspected
hepatitis A virus infection? .................................................................................................
If yes, was the contact (check one)
•
household member (non-sexual) ...................................................................................
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sex partner ......................................................................................................................
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child cared for by this patient .......................................................................................
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babysitter of this patient ...............................................................................................
•
playmate ..........................................................................................................................
•
other
_____________________________________
Was the patient
•
a child or employee in a day care center, nursery, or preschool ? ..........................
•
a household contact of a child or employee in a
day care center, nursery or preschool ? ....................................................................
If yes for either of these, was there an identified hepatitis A case
in the child care facility? ............................................................................................
Please ask both of the following questions regardless of the patient’s gender.
0
1
2-5
>5 Unk
In the 2- 6 weeks before symptom onset how many
•
male sex partners did the patient have? ....................................................
•
female sex partners did the patient have? ................................................
In the 2- 6 weeks before symptom onset
Yes
No
Unk
Did the patient inject drugs not prescribed by a doctor? .............................................
Did the patient use street drugs but not inject? ............................................................
Did the patient travel outside of the U.S.A. or Canada .............................................
•
If yes, where? 1) _________________ 2) _________________
(Country)
3) _________________
In the 3 months prior to symptom onset
Did anyone in the patient’s household travel outside of the U.S. A. or Canada?
•
If yes, where?
1) _________________ 2) _________________
(Country)
3) _________________
Is the patient suspected as being part of a common-source outbreak? ..........................
If yes, was the outbreak
Foodborne- associated with an infected food handler ................................................
Foodborne - NOT associated with an infected food handler ....................................
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specify food item
_____________________________________
Waterborne ......................................................................................................................
Source not identified .......................................................................................................
Was the patient employed as a food handler during the TWO WEEKS
prior to onset of symptoms or while ill? ..............................................................................
VACCINATION HISTORY
Yes
No
Unk
Has the patient ever received the hepatitis A vaccine ?
≥ ≥ ≥ ≥ ≥
1
2
•
If yes, how many doses? ................................................
Y
Y
Y
•
Y
In what year was the last dose received? ..................
Yes
No
Unk
Has the patient ever received immune globulin ? ...........
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If yes, when was the last dose received? ...................... ______ / _____
mo
yr
2
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