California Department Of Public Health Confidential Morbidity Report
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1
2California Department of Public Health
State of California—Health and Human Services Agency
CONFIDENTIAL MORBIDITY REPORT
NOTE: For STD, Hepatitis, or TB, complete appropriate section below. Special reporting requirements and reportable diseases on back.
DISEASE BEING REPORTED:
___________________________________________________________________________________
Ethnicity (✓ one)
Patient’s Last Name
Social Security Number
❒
–
–
Hispanic/Latino
❒
Non-Hispanic/Non-Latino
Birth Date
Age
First Name/Middle Name (or initial)
Race (✓ one)
Month
Day
Year
❒
African-American/Black
❒
Asian/Pacific Islander (✓ one):
Address: Number, Street
Apt./Unit Number
❒
❒
Asian-Indian
Japanese
❒
❒
Cambodian
Korean
❒
❒
City/Town
State
ZIP Code
Chinese
Laotian
❒
❒
Filipino
Samoan
❒
❒
Guamanian
Vietnamese
Estimated Delivery Date
Area Code
Home Telephone
Gender
Pregnant?
❒
Month
Day
Year
Hawaiian
–
–
❒
M
F
N
Y
Unk
Other:________________________
❒
Native American/Alaskan Native
Area Code
Work Telephone
Patient’s Occupation/Setting
❒
❒
❒
❒
White: __________________________
–
Food service
Day care
Correctional facility
–
❒
❒
❒
❒
Other: __________________________
Health care
School
Other _________________________
Reporting Health Care Provider
DATE OF ONSET
REPORT TO
Month
Day
Year
Reporting Health Care Facility
DATE DIAGNOSED
Address
Month
Day
Year
City
State
ZIP Code
DATE OF DEATH
Telephone Number
Fax
(
)
(
)
Month
Day
Year
Submitted by
Date Submitted
(Month/Day/Year)
(Obtain additional forms from your local health department.)
SEXUALLY TRANSMITTED DISEASES (STD)
VIRAL HEPATITIS
Not
Pos
Neg
Pend Done
Syphilis
Syphilis Test Results
❒ Hep A
❒
❒
❒
❒
❒
❒
❒
anti-HAV IgM
Primary (lesion present)
Late latent > 1 year
RPR
Titer:__________
❒
❒
❒
❒ Hep B
❒
❒
❒
❒
Secondary
Late (tertiary)
VDRL
Titer:__________
HBsAg
❒
❒
❒
❒
❒
❒
❒
❒
❒
❒ Acute
Early latent < 1 year
Congenital
FTA/MHA:
Pos
Neg
anti-HBc
❒
❒
❒
❒
❒
❒
❒
❒
❒ Chronic
Latent (unknown duration)
CSF-VDRL:
Pos
Neg
anti-HBc IgM
❒
❒
❒
❒
❒ Neurosyphilis
❒
Other:_________________
anti-HBs
❒ Hep C
❒
❒
❒
❒
Gonorrhea
Chlamydia
anti-HCV
❒ PID (Unknown Etiology)
❒
❒
❒ Acute
❒
❒
❒
❒
Urethral/Cervical
Urethral/Cervical
❒ Chancroid
PCR-HCV
❒
❒
❒ Chronic
PID
PID
❒ Non-Gonococcal Urethritis
❒
❒
Other: ____________________
Other: _____________
❒ Hep D (Delta)
❒
❒
❒
❒
anti-Delta
❒ Untreated
❒ Other: ______________
❒
❒
❒
❒
STD TREATMENT INFORMATION
❒ Treated (Drugs, Dosage, Route):
❒
Date Treatment Initiated
Will treat
Suspected Exposure Type
❒
Unable to contact patient
❒
❒
❒
❒
Month
Day
Year
____________________________
Blood
Other needle
Sexual
Household
❒
Refused treatment
transfusion
exposure
contact
contact
____________________________
❒
❒
❒
Referred to: _________________
Child care
Other: ________________________________
TUBERCULOSIS (TB)
TB TREATMENT INFORMATION
❒ Current Treatment
Status
Mantoux TB Skin Test
Bacteriology
❒ Active Disease
❒
❒
❒
INH
RIF
PZA
Month
Day
Year
Month
Day
Year
❒
❒
❒
____________
Confirmed
EMB
Other:
❒
Suspected
Date Performed
Date Specimen Collected
Month
Day
Year
❒ Infected, No Disease
❒
Pending
Date Treatment
❒
❒
Convertor
Results:______________ mm
Not Done
Source _______________________________________
Initiated
❒
❒
❒
❒
❒
Reactor
Smear:
Pos
Neg
Pending
Not done
❒
❒
❒
❒
❒ Untreated
Chest X-Ray
Culture:
Pos
Neg
Pending
Not done
Month
Day
Year
❒
Site(s)
Will treat
❒
Date Performed
❒
Pulmonary
Other test(s) ___________________________________
Unable to contact patient
❒
❒
❒
❒
❒
Extra-Pulmonary
Normal
Pending
Not done
Refused treatment
❒
❒
❒
❒
_______________________________________
Both
Cavitary
Abnormal/Noncavitary
Referred to: _____________________
REMARKS
PM 110 (revised 10/30/08)
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