Infectious Diseases Requisition Form
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1
2Infectious Diseases Requisition
New York State Department of Health
Wadsworth Center
NYS Accession Number
Empire State Plaza
PO Box 509, Albany, NY 12201-0509
Date received
/
/
Shipping address:
Telephone: (518) 474-4177
*
Patient Demographics
denotes required information
/
/
Male
Female
*
*
*
Last Name
First Name
MI
DOB
Sex
Street Address
City
State
Zip Code
*
NYS County of Residence
NYS DOH Outbreak Number
CDESS Case Number
Submitter’s Reference Number
*
Submitter (Laboratory report will be sent to)
denotes required information
*
Name and Address
Laboratory PFI
Name
Contact Person
Address
Telephone Number (
)
-
ext.
City
State
Zip
*
Specimen Information
denotes required information
Specimen is:
Isolate
Primary Specimen
Autopsy Specimen
Collection Date *
/
/
MM
DD
YYYY
*
Source / Specimen Type
Time Collected
:
(if applicable for test)
(HH : MM)
Laboratory Examination Requested
Bacterial
Fungal
Mycobacterial
Parasitic
Serology
Viral
Suspected Organism / Agent
Identification / Confirmation
Susceptibility (specify antimicrobial(s))
TB Fast Track
Serology (specify test and define onset date)
Viral Encephalitis Panel
Other (specify)
Submitting lab findings: Smear/Stain/Other results
Comments
Specimen submitted on/in:
Media
Preservative
Tissue cell line
Relevant Exposure:
Contact known case
Food/water
Nosocomial
Travel
Animal
Arthropod
Location & Dates
Type
Type
Clinical History
(
)
-
ext.
Name of patient’s healthcare provider
Telephone Number
Diagnosis:
Hospitalized?
Yes
No
Unknown
If hospitalized, hospital name:
Pregnant (trimester):
Symptoms:
Acute
Chronic
Other
Onset of symptoms:
/
/
MM
DD
YYYY
Fever: max
duration
CSF: Glu
Prot
RBC
WBC
Relevant Treatment:
Date
/
/
Relevant Immunization:
Date
/
/
Symptoms/Clinical Epidemiology (check all that apply):
Central Nervous System:
Altered Mental Status
Coma
Encephalitis
Headache
Meningitis
Paralysis
Seizures
Gastrointestinal:
Diarrhea
Blood/Mucus
Nausea
Vomiting
Respiratory:
Bronchitis
Bronchiolitis
Cough
Pneumonia
Upper Respiratory Infection
Skin/hair/nails:
Hemorrhagic
Maculopapular Rash
Petechial Rash
Vesicular
Cardiovascular:
Endocarditis
Myocarditis
Pericarditis
Miscellaneous:
Arthralgia
Conjunctivitis
Cystitis
Hepatitis
Hepatomegaly
Immunocompromised
Jaundice
Keratitis
Lymphadenopathy
Malaise
Myalgia
Pleurodynia
Splenomegaly
Ulcer(s)
Urethritis
Other Symptoms:
DOH-4463 (6/09) p. 1 of 2 Non-Human Sample form on page 2
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