Virology Test Request - Missouri State Public Health Laboratory

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MISSOURI DEPARTMENT OF HEALTH & SENIOR SERVICES
101 NORTH CHESTNUT STREET, PO BOX 570
MISSOURI STATE PUBLIC HEALTH LABORATORY
JEFFERSON CITY, MO 65101
(573) 751-3334
VIROLOGY TEST REQUEST
SUBMITTER INFORMATION (RESULTS ARE RETURNED TO THIS ADDRESS)
SUBMITTER NUMBER
FACILITY NAME
BOONE HOSPITAL LAB
1064
ADDRESS
CITY
STATE
ZIP CODE
MO
65201
1600 E BROADWAY
COLUMBIA
OUTSIDE FACILITY NUMBER/NAME
SUBMITTER CONTACT NAME
SUBMITTER PHONE NUMBER
ATTENDING PHYSICIAN/CLINICIAN INFORMATION OR VETERINARIAN (FOR ANIMAL SAMPLES)
PHYSICIAN NAME (LAST, FIRST)
PHYSICIAN TELEPHONE
VETERINARIAN NAME (LAST, FIRST)
VETERINARIAN TELEPHONE
PHYSICIAN STATE
PHYSICIAN ZIP CODE
PHYSICIAN ADDRESS
PHYSICIAN CITY
PATIENT INFORMATION OR RABIES EXPOSURE
FIRST NAME
LAST NAME
M.I.
PATIENT ID
ADDRESS
CITY
STATE
ZIP CODE
GENDER
BIRTH DATE
ETHNICITY
Hispanic
Non Hispanic
Unknown
Female
Male
RACE
White
Black
Asian
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Other
Unknown
MEDICAL RECORD/CHART ID
MEDICAID NUMBER
COUNTY OF RABIES EXPOSURE
EXPOSED PERSON TELEPHONE NO.
SPECIMEN TYPE - Check appropriate specimen and fill in requested information (ONLY one sample per form)
DATE COLLECTED
SPECIMEN ID
Swab - Nasopharyngeal
Serum
Animal (Rabies only)
Exposure (Rabies only)
Emesis (Vomit)
Dog
Human
Swab - Other: _________________
Blood
Lesion Roof/Scab
Pet/Domestic Animal
Cat
Resp. Wash/Aspirate
CSF
Touch Prep. Slides
Significant Potential
Bat
Dry Swab
Wound/Tissue/Biopsy
Stool
Details of incident: _________
Other: __________
Swab - Throat
Source: _________________
Urine
_________________________
________________
Other: __________________
_________________________
_________________________
PATIENT HISTORY
DATE OF ONSET
VIRUS ISOLATION INFORMATION: INFLUENZA VACCINATION
RUBEOLA/RUBELLA VACCINATION DATE
YES DATE:
NO
SEROLOGY INFORMATION
EPIDEMIOLOGICAL DATA
ACUTE DATE
CONVALESCENT DATE
INCIDENCE
Single Case
Outbreak
TEST(S) REQUESTED
Serology
Virus Isolation
Hepatitis
Molecular (PCR)
Rabies (Animal Only)
Measles
Gastrointestinal
Influenza A & B
Hepatitis A:
Rabies FA
Rubella
Parainfluenza
anti-HAV IgM
Arbovirus
Adenovirus
Hepatitis B:
Rash Investigation
Rickettsial Panel
Enterovirus
Pregnant (HBsAg)
CDC Referral:
Cytomegalovirus (CMV)
Prenatal Contact (anti-HBc)
Respiratory
Varicella Zoster
Infant Serology (anti-HBs)
Other:
Mumps
Refugee Screen (HBsAg)
Other:
ELISA Testing:
Respiratory Syncytial Virus (RSV)
Adenovirus 1-41
Rotavirus
Page 1 of 2
MO 580-2941 (06-11)
LAB 158

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