Morbidity Report Form - City Of Houston
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1MORBIDITY REPORT FORM
Houston Department of Health and Human Services
8000 North Stadium Drive
Houston, Texas 77054
832-393-5080
Fax: (832)393-5232 [Do NOT fax HIV/AIDS-related patient information]
Reported By
:
Date
:
Case Number :
PATIENT DEMOGRAPHIC DATA
Last Name
:
FirstName & MI :
DOB
:
Age
:
Sex :
Race/Ethnicity
:
SocSecNumber :
Address
:
City, Zipcode
:
Home Phone :
(
)
--
Occupation/Work Place
:
Tel: (
)
--
School/Day Care Center
:
Tel: (
)
--
:
Parent/Contact Person
Tel: (
)
--
DISEASE DATA
Date of Onset:
REPORTABLE DISEASE/ORGANISM:
Species/serotype
:
Source of
Date of
Diagnostic test
Source of
Date of
Diagnostic test
Specimen
Collection
and Result
Specimen
Collection
and Result
Anti-HAV IgM _____
Anti-HBc IgM ___
Anti-HCV
___
Specific Viral
A
ST/SGOT ___
Anti-HAV Total _____
Anti-HBc Total ___
HCV RIBA ___
ALT/SGPT ___
Hepatitis Studies
Anti-HBs
___
HCV RNA
HbsAg
___
by PCR
___
HbeAg
___
HOSPITAL or CLINIC DATA
Hospital/Clinic
:
Attending Physician
:
Medical RecNumber
:
Address
:
Date Admitted
:
Date Discharged
:
Pager/Phone
:
Date Expired
:
Other Physician
:
Comments/patient history/risk factors:
Investigator:
FOR OFFICIAL USE ONLY
FILENO:
RPTBY
:
HSA:
INTRV :
STATUS :
KMAP :
CENTRCT:
DX :
OCCUP:
Rev. 10/1999
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