Infectious Diseases Requisition
Infectious Diseases Requisition
New York State Department of Health
New York State Department of Health
New York State Department of Health
Wadsworth Center
Wadsworth Center
Wadsworth Center
NYS Accession Number
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
Contact Person
Telephone Number (
Number (
Number (
)
)
)
-
-
-
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
Serology
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 fi ndings: 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
(
)
-
Name of patient’s healthcare provider
Telephone Number
Diagnosis:
Diagnosis:
Hospitalized?
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