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U w { U U N N J U N R U " b eH R C \ 4
M T L 9 Q . 9 h 9 W Z @ 4 % 0 W W W j W W W U U U U d J
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g N N N N N N Novel and Pandemic Influenza Case Investigation Form
Interview Date:______________( MMDDYYYY)
Report Date:______________( MMDDYYYY)
State EPI ID# (epidemiology ID): __________________ CDC EPI ID (Case): _______________
Cluster ID: _____________________ Cluster Name:_______________________
Case Status: m C o n f i r m e d C a s e D a t e : _ _ _ _ _ _ _ _ ( M M D D Y Y Y Y )
m P r o b a b l e C a s e D a t e : _ _ _ _ _ _ _ _ ( M M D D Y Y Y Y )
m S u s p e c t C a s e D a t e : _ _ _ _ _ _ _ _ ( M M D D Y Y Y Y )
m N o t a C a s e D a t e : _ _ _ _ _ _ _ _ ( M M D D Y Y Y Y )
S o u r c e o f I n f o r m a t i o n
m P e r s o n m P r o x y ( e g . p e r s o n n o t a v a i l a b l e ; child too young, person died, etc.) :
IF proxy, relationship to contact _____________________
Proxy First Name ________________Proxy Last Name_______________________
Address ____________________________________________________________
City______________________________State_______Zip__________________
Email __________________ Phone ( ___)_________ Cell Phone (_____)________
Reporter Information (CDC staff: enter CDC UserID in FirstName field and no other information)
Reporter FirstName __________________LastName________________________
Reporters Organization Name______________________________________________________
Address_________________________________City_____________________State______ Zip________
Phone Number :( )_____ _______ Fax Number :( )_____ _______
E-Mail: _____________________ County: _________________
Demographic Information
Name First_____________________________ Last __________________________
DOB (mm/dd/yy) ____/____/____ S e x ( c i r c l e o n e ) M F
A g e _ _ _ _ _ _ m y r s m m o ( f o r i n f a n t s u p t o 1 1 m o ; 0 m o = < 1 m o o l d )
R a c e : m W h i t e ( 1 ) m N a t i v e H a w a i i a n / O t h e r P a c i f i c I s l a n d e r ( 4 ) m M u l t i r a c i a l ( 6 )
m B l a c k ( 2 ) m A m e r i c a n I n d i a n / A l a s k a N a t i v e ( 5 ) m U n k n o w n / O t h e r ( 9 )
m A s i a n ( 3 )
E t h n i c i t y : m H i s p a n i c m N o n - H i s p a n i c m U n k n o w n / O t h e r
A d d r e s s _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
C i t y _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S t a t e _ _ _ _ _ _ _ _ _ _ _ Z i p _ _ _ _ _ _ _ _ _ _ _ _ _ _ C o u n t r y ( i f n o t U S ) _ _ _ _ _ _ _ _ _ _
G P S ( i f needed) _____________ (latitude X longitude) County__________________
Email address __________________________ Phone ( ______)_________________________
Occupation ___________________________________Cell Phone (________)_________________
Social History and Contact Tracing
Number of household members* _____
*(Anyone (including case patient) with at least one overnight stay +/- 7 days from illness onset)
Name1________________ Relationship ___________ Age _______ mo / yrs (circle) Hi-risk*: Y / N (circle)
Name2________________ Relationship ___________ Age _______ mo / yrs (circle) Hi-risk*: Y / N (circle)
Name3________________ Relationship ___________ Age _______ mo / yrs (circle) Hi-risk*: Y / N (circle)
Name4________________ Relationship ___________ Age _______ mo / yrs (circle) Hi-risk*: Y / N (circle)
Name5________________ Relationship ___________ Age _______ mo / yrs (circle) Hi-risk*: Y / N (circle)
Name6________________ Relationship ___________ Age _______ mo / yrs (circle) Hi-risk*: Y / N (circle)
Name7________________ Relationship ___________ Age _______ mo / yrs (circle) Hi-risk*: Y / N (circle)
Name8________________ Relationship ___________ Age _______ mo / yrs (circle) Hi-risk*: Y / N (circle)
* household member has medical condition that puts them at higher risk for influenza complications
Has anyone in your household had fever, cough, sore throat, or s y m p t o m s s i m i l a r t o w h a t t h e c a s e - p a t i e n t r e p o r t e d ?
m Y e s ( c o m p l e t e c o n t a c t f o r m ) m N o m N / A m U n k n o w n
[ I f Y E S , l i s t a n y i d e n t i f i e d c o n t a c t s o n t h e c o n t a c t t r a c i n g f o r m ]
H a v e o u t - o f - t o w n g u e s t s v i s i t e d y o u ? Y e s N o U n k n o w n
I f y e s , w h e r e d i d t h e y t r a v e l f r o m ? O r i g i n : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
( i n c l u d e s t a t e a n d a l s o c o u n t r y i f o u t s i d e U S )
D a t e s o f v i s i t o r s : F r o m _ _ _ _ / _ _ _ _ / _ _ _ _ t o _ _ _ _ / _ _ _ _ / _ _ _ _ U n k n o w n
W a s a n y o n e i l l o r b e c a m e i l l ? Y e s N o U n k n o w n
[ I f Y E S , l i s t a n y i d e n t i f i e d c o n t a c t s o n t h e c o n t a c t t r a c i n g f o r m ]
D a t e s I l l : F r o m _ _ _ _ / _ _ _ _ / _ _ _ _ t o _ _ _ _ / _ _ _ _ / _ _ _ _ U n k n o w n
W h a t i s t h e c u r r e n t j o b o f t h e c a s e - p a t i e n t ?
m L a b o r a t o r y w o r k e r m H e a l t h c a r e w o r k e r m P o u l t r y f a r m - w o r k e r m W i l d l i f e w o r k e r
m V e t e r i n a r y w o r k e r m S w i n e f a r m - w o r k e r m S c h o o l w o r k e r , i n c l t e a c h e r m F i r s t - r e s p o n d e r s
m C h i l d c a r e w o r k e r m S t u d e n t ( i f c o l l e g e / u n i v e r s i t y , p l e a s e l i s t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ )
m O t h e r _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ m O t h e r a n i m a l h u s b a n d r y _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
E m p l o y e r N a m e : _ _ _ _ _ _ _ _ _ _ _ E m p l o y e r P h o n e # : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D o e s t h e c a s e - p a t i e n t w o r k i n a h e a l t h c a r e f a c i l i t y o r s e t t i n g ?
m Y e s ( s p e c i f y n a m e ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ m N o m U n k n o w n
E x p o s u r e s - T r a v e l h i s t o r y
I n t h e 7 d a y s p r i o r t o i l l n e s s o n s e t , d i d t h e c a s e - p a t i e n t t r a v e l ?
m Y e s m N o m U n k n o w n
I f Y E S , p l e a s e f i l l i n t h e a p p r o p r i a t e t r a v e l i n f o r m a t i o n f o r a n y t r a v e l o u t o f t o w n , i n c l u d i n g o u t o f s t a t e o r i n t e r n a t i o n a l l y . I f y o u t o o k a m u l t i - l e g f l i g h t , e a c h l e g r e p r e s e n t s a d e s t i n a t i o n .
a . D e s t i n a t i o n 1 : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D a t e s o f t r a v e l : F r o m _ _ _ _ / _ _ _ _ / _ _ _ _ t o _ _ _ _ / _ _ _ _ / _ _ _ _ D o n t K n o w
P u r p o s e o f t r a v e l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
M o d e o f t r a v e l : _ _ _ _ _ _ _ _ _ _ _ _______________Flight/Ship #:____________________
Miscellaneous (if less than 1 day, indicate how many minutes here): ________________________________
Destination2: _____________________________________________
Dates of travel: From ____/____/____ to ____/____/____ D o n t K n o w
P u r p o s e o f t r a v e l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
M o d e o f t r a v e l : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ F l i g h t / S h i p # : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
M i s c e l l a n e o u s ( i f l e s s t h a n 1 d a y , i n d i c a t e h o w m a n y m i n u t e s h e r e ) : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
c . D e s t i n a t i o n 3 : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D a t e s o f t r a v e l : F r o m _ _ _ _ / _ _ _ _ / _ _ _ _ t o _ _ _ _ / _ _ _ _ / _ _ _ _ D o n t K n o w
P u r p o s e o f t r a v e l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
M o d e o f t r a v e l : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __Flight/Ship #:____________________
Miscellaneous (if less than 1 day, indicate how many minutes here): ________________________________
d. Destination4: _____________________________________________
Dates of travel: From ____/____/____ to ____/____/____ D o n t K n o w
P u r p o s e o f t r a v e l _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
M o d e o f t r a v e l : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ F l i g h t / S h i p # : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
M i s c e l l a n e o u s ( i f l e s s t h a n 1 d a y , i n d i c a t e h o w m a n y m i n u t e s h e r e ) : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______
Exposures-Contact with probable or confirmed case-patients
In the 7 days prior to illness onset in the case patient:
Did the case-patient have close contact (within 2 meter (or 6 feet)) with a person (e.g. caring for, speaking with, or touching) with fever and cough, or pneumonia, or that died of a respiratory illness in the 7 days prior to illness onset?
m Y e s m N o m U n k n o w n
I f Y E S , w a s t h e c o n t a c t i n t h e U . S . A . o r i n t e r n a t i o n a l ?
m U S m I n t e r n a t i o n a l m U n k n o w n
W h e r e ?
S t a t e / C o u n t r y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e ( s ) o f C o n t a c t : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
S t a t e / C o u n t r y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date(s) of Contact: __________________________________________________
In the 7 days prior to illness onset in the case patient:
Did the case-patient have close contact (within 2 meter (6 feet)) with a person (e.g. caring for, speaking with, or touching) who is a suspected, probable or confirmed novel human influenza A case within the week prior to illness onset?
m Y E S m N o m U n k n o w n
I f Y E S :
a . D i d t h e p a t i e n t d i r e c t l y t o u c h o r p r o v i d e p h y s i c a l c a r e f o r t h e p r o b a b l e o r c o n f i r m e d c a s e ?
m Y E S m N o m U n k n o w n
b . D i d t h e p a t i e n t s p e a k t o o r t o u c h o r a n y i t e m s b e l o n g i n g t o t h e p r o b a b l e o r c o n f i r m e d c a s e ?
m Y E S m N o m U n k n o w n
I n t h e 7 d a y s p r i o r t o i l l n e s s o n s e t :
D i d t h e c a s e - p a t i e n t v i s i t o r s t a y i n t h e s a m e h o u s e h o l d w i t h a n y o n e w h o d i e d d u r i n g o r f o l l o w i n g t h e v i s i t ?
m Y e s m N o m U n k n o w n
I n t h e 7 d a y s p r i o r t o i l l n e s s o n s e t :
D i d t h e c a s e - p a t i e n t s e e k c a r e f o r a n u n r e l a t e d h e a l t h c o n d i t i o n .
m Y e s m N o m U n k n o w n
I F Y E S , w h e r e d i d t h e y g o :
N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ C o u n t y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ D a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
E x p o s u r e s - C o n t a c t w i t h P o u l t r y , S w i n e a n d O t h e r A n i m a l s
A r e t h e r e a n y s i c k o r d e a d a n i m a l ( s ) p r e s e n t t o d a y i n t h e c a s e - p a t i e n t s h o m e , o n y o u r f a r m o r a t y o u r w o r k p l a c e ?
m Y e s m N o m U n k n o w n
I f Y E S , w h i c h o f f o l l o w i n g a r e p r e s e n t ?
m C a t m D o g m S w i n e m P o u l t r y m W i l d b i r d s
m O t h e r ( s p e c i f y ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
I f Y E S , i n t h e t w o w e e k s p r i o r t o t h e c a s e - p a t i e n t s i l l n e s s o n s e t , w h a t w a s t h e s t a t u s o f t h e a n i m a l s ?
m W e l l - a p p e a r i n g m D i s e a s e d m D e a d ( a p p r d a t e o f d e a t h ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
I n t h e 7 d a y s p r i o r t o i l l n e s s o n s e t , d i d t h e c a s e - p a t i e n t h a v e c o n t a c t w i t h a n y o f t h e f o l l o w i n g a n i m a l s ? ( c h e c k a l l t h a t a p p l y )
m S w i n e m P o u l t r y m W i l d b i r d s m O t h e r ( s p e c i f y ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
I f t h e p a t i e n t h a d c o n t a c t w i t h a n i m a l s , p l e a s e a n s w e r t h e f o l l o w i n g q u e s t i o n s , o t h e r w i s e s k i p t o t h e M e d i c a l H i s t o r y s e c t i o n :
W h a t w a s t h e n a t u r e o f t h e c o n t a c t ( c h e c k a l l t h a t a p p l y ) ?
m D i r e c t t o u c h i n g ( s p e c i f y a n i m a l ( s ) ) _ _ _ _ _ _ _ _ _ _ _ _
m P r o x i m i t y w i t h i n 1 m e t e r b u t n o t t o u c h i n g ( s p e c i f y a n i m a l ( s ) ) _ _ _ _ _ _ _ _ _ _ _ _ _ _
I f t h e c a s e - p a t i e n t d i r e c t l y t o u c h e d t h e b i r d ( s ) o r o t h e r a n i m a l ( s ) , w h i c h o f t h e f o l l o w i n g d i d t h e p a t i e n t d o w i t h t h e a n i m a l : ( c h e c k a l l t h a t a p p l y )
H a n d l e / R o u t i n e h u s b a n d r y m S l a u g h t e r / b u t c h e r m P r e p a r e f o r c o n s u m p t i o n m O t h e r ( s p e c i f y ) _ _ _ _ _ _ _ _ _ _ _ _ _ _
W h e r e d i d t h e c o n t a c t o c c u r ?
H o m e / F a r m m I n s i d e h o m e m B a c k y a r d a n i m a l s ,
W o r k - r e l a t e d m S l a u g h t e r h o u s e m V e t e r i n a r y c o n t a c t m C o m m e r c i a l a n i m a l f a r m
L i v e a n i m a l m a r k e t m L i v e B i r d M a r k e t m L i v e s t o c k S a l e s m S w a p m e e t / F l e a m a r k e t
R e c r e a t i o n a l m P e t t i n g z o o m A g r i c u l t u r a l e x h i b i t i o n
O u t d o o r s m W i l d l i f e m H u n t i n g
m O t h e r c o n t a c t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D i d t h e c a s e - p a t i e n t c o n s u m e r a w o r u n d e r c o o k e d a n i m a l s ( i n c l u d i n g p o u l t r y , w i l d b i r d s , o r s w i n e p r o d u c t s ) i n a n a r e a w h e r e i n f l u e n z a i n f e c t i o n s i n a n i m a l s o r n o v e l i n f l u e n z a i n h u m a n s h a s b e e n s u s p e c t e d o r c o n f i r m e d ?
m Y e s m N o m U n k n o w n
D i d t h e c a s e - p a t i e n t h a n d l e s a m p l e s ( a n i m a l o r h u m a n ) s u s p e c t e d o f c o n t a i n i n g i n f l u e n z a v i r u s i n a l a b o r a t o r y o r o t h e r s e t t i n g ?
m Y e s m N o m U n k n o w n
N a r r a t i v e : ( I m p r e s s i o n of exposures including field assessment of most suspicious; may list in order of suspicion)_____________________
________________________________________________________________________________________________________________________________________________________________________________________________________________
Medical History-Vaccination Status
Did the case patient receive influenza vaccination between September 2008 and today?
Y e s N o U n k n o w n
I f y e s , n u m b e r o f d o s e s : 1 2
D o s e 1 : D a t e ( M M D D Y Y Y Y ) _ _ _ _ / _ _ _ _ / _ _ _ _ [ I f d a y o f m o n t h u n k n o w n , u s e 1 5 ]
T y p e o f v a c c i n e : I n a c t i v a t e d ( i n j e c t a b l e ) L i v e A t t e n u a t e d ( s p r a y ) U n k n o w n
D o s e 2 : D a t e ( M M D D Y Y Y Y ) _ _ _ _ / _ _ _ _ / _ _ _ _ [ I f d a y o f m o n t h u n k n o w n . u s e 1 5 ]
T y p e o f v a c c i n e : I n a c t i v a t e d ( i n j e c t a b l e ) L i v e A t t e n u a t e d ( s p r a y ) U n k n o w n
M e d i c a l H i s t o r y - P a s t M e d i c a l H i s t o r y / P r e g n a n c y S t a t u s
D o y o u h a v e a n y o f t h e f o l l o w i n g m e d i c a l c o n d i t i o n s ?
a . A s t h m a . . . . . . . . . . . . . . . . . . . . . . . Y e s N o U n k n o w n
I f y e s , d o y o u c u r r e n t l y t a k e m e d i c a t i o n t o c o n t r o l y o u r a s t h m a ? Y e s N o U n k n o w n
O t h e r c h r o n i c l u n g d i s e a s e . . . . . Y e s ( S p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) N o U n k n o w n
C h r o n i c h e a r t o r c i r c u l a t o r y d i s e a s e . . Y e s ( S p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) N o U n k n o w n
d . M e t a b o l i c d i s e a s e ( i n c l u d i n g d i a b e t e s ) Y e s ( S p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) N o U n k n o w n
I f y e s , d o y o u c u r r e n t l y t a k e m e d i c a t i o n t o c o n t r o l y o u r d i s e a s e ? Y e s N o U n k n o w n
e . K i d n e y d i s e a s e . . . . . . . . . . Y e s ( S p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) N o U n k n o w n
f . C a n c e r i n t h e l a s t 1 2 m o n t h s . . . . . Y e s ( S p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) N o U n k n o w n
g . I m m u n o s u p p r e s s i v e c o n d i t i o n ( H I V I n f e c t i o n , c a n c e r , c h r o n i c c o r t i c o s t e r o i d o r o t h e r i m m u n o s u p p r e s s i v e t h e r a p y , o r o r g a n t r a n s p l a n t r e c i p i e n t ) . Y e s ( S p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) N o U n k n o w n
h . N e u r o l o g i c / n e u r o m u s c u l a r d i s o r d e r . Y e s ( S p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) N o U n k n o w n
i . H e m a g l o b i n o p a t h y . . . . , , , . Y e s ( S p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) N o U n k n o w n
j . O t h e r c h r o n i c d i s e a s e s . . . . . . Y e s ( S p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ ) N o U n k n o w n
k . P r e g n a n t . . . . . . . . . . . Y e s N o U n k n o w n
I f p r e g n a n t , s p e c i f y c u r r e n t w e e k s o f g e s t a t i o n _ _ _ _ _ _ _ _ _ _ ( a s o f t o d a y )
I f p r e g n a n t , s p e c i f y e s t i m a t e d d a t e o f c o n f i n e m e n t ( E D C ) o r d u e d a t e : _ _ _ _ _ _ _ _ _ _ ( M M D D Y Y Y Y )
D o e s t h e c a s e - p a t i e n t c u r r e n t l y s m o k e c i g a r e t t e s ? e v e r y d a y s o m e d a y s n o t a t a l l
M e d i c a l H i s t o r y - I l l n e s s o n s e t a n d p r e s e n t i n g s y m p t o m s
D a t e o f i l l n e s s o n s e t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ( D D / M M / Y Y Y Y )
D a t e ( s ) o f o u t p a t i e n t m e d i c a l p r e s e n t a t i o n ( s) (clinic location, name):
Clinic #1 name: __________________ Date(s): ___________ (MMDDYYYY) Telephone #: ___________Fax #: __________
Address: __________________________________________________________________________
Clinic #2 name: __________________ Date(s): ____________ (MMDDYYYY) Telephone #: ____________Fax #: _________
Address: __________________________________________________________________________
Was the case-patient hospitalized?
m Y e s m N o m U n k n o w n
D a t e ( s ) o f h o s p i t a l a d m i s s i o n ( s ) : [ c o n s i d e r c l i n i c a l d e s c r i p t i o n o f h o s p i t a l i z e d p a t i e n t s f o r m ]
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dh ^` gde dh `gde dh gde _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
A d m i s s i o n d a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ( M M D D Y Y Y Y )
m D i s c h a r g e d ( s p e c i f y d a t e ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ m T r a n s f e r r e d ( s p e c i f y d a t e ) _ _ _ _ _ _ _ _ _ _ _
H o s p i t a l # 2 N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ T e l e p h o n e # _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ F a x # : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
A d d r e s s : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
A d m i s s i o n d a t e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ( M M D D Y Y Y Y )
m D i s c h a r g e d ( s p e c i f y d a t e ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ m T r a n s f e r r e d ( s p e c i f y d a t e ) _ _ _ _ _ _ _ _ _ _ _
W i t h i n t h e l a s t 7 d a y s , h a s t h e c a s e - p a t i e n t e x p e r i e n c e d a n y o f t h e f o l l o w i n g m e d i c a l c o n d i t i o n s :
C o u g h i n g Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
D i a r r h e a Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
D i f f i c u l t y b r e a t h i n g Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
( o r s h o r t n e s s o f b r e a t h )
C o n j u n t i v i t i s Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
F e v e r ( _ _ _ _ _ ) t e m p i f k n o w n Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
F e v e r i s h n e s s Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
H e a d a c h e Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
M u s c l e a c h e s Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
R a s h Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
R h i n o r r h e a Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
S e i z u r e s Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
S o r e t h r o a t Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
V o m i t i n g Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
O t h e r s y m p t o m ( s ) Y E S ( D a t e _ _ _ _ / _ _ _ _ / _ _ _ _ ) N O m U n k n o w n
( s p e c i f y ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
M e d i c a l H i s t o r y - T r e a t m e n t , C l i n i c a l C o u r s e , a n d O u t c o m e
D i d t h e c a s e - p a t i e n t r e c e i v e a n t i v i r a l m e d i c a t i o n s t o t r e a t i n f l u e n z a ?
m Y e s m N o m U n k n o w n
D i d t h e c a s e - p a t i e n t r e c e i v e a n t i v i r a l m e d i c a t i o n s t o p r e v e n t i n f l u e n z a ?
m Y e s m N o m U n k n o w n
I f a n t i v i r a l t r e a t m e n t w a s u s e d t o t r e a t a n d / o r t o p r e v e n t i n f l u e n z a , c o m p l e t e t a b l e b e l o w
D r u g
D o s e # 1 D o s e # 1
D a t e I n i t i a t e d
( M M D D Y Y Y Y ) D o s e # 1
D a t e D i s c o n t i n u e d
( M M D D Y Y Y Y ) *
D o s e # 2 D o s e # 2
D a t e I n i t i a t e d
( M M D D Y Y Y Y ) D o s e # 2
D a t e D i s c o n t i n u e d
( M M D D Y Y Y Y ) * O s e l t a m i v i r ( T a m i f l u ) m g m g Z a n a m i v i r ( R e l e n z a ) m g m g R i m a n t a d i n e m g m g A m a n t a d i n e m g m g O t h e r _ _ _ _ _ _ _ _ _ _ _ _ * L e a v e D a t e D i s c o n t i n u e d b l a n k i f s t i l l t a k i n g .
D i d t h e c a s e - p a t i e n t r e c e i v e a n t i b a c t e r i a l m e d i c a t i o n s ?
m Y e s m N o m U n k n o w n
I f y e s , c o m p l e t e t a b l e b e l o w
D r u g D a t e I n i t i a t e d D a t e D i s c o n t i n u e d * D o s a g e ( i f k n o w n ) m g m g m g m g * L e a v e D a t e D i s c o n t i n u e d b l a n k i f s t i l l t a k i n g .
D i d t h e c a s e - p a t i e n t r e c e i v e s t e r o i d s ?
m Y e s m N o m U n k n o w n
I f y e s , c o m p l e t e t a b l e b e l o w
D r u g D a t e I n i t i a t e d D a t e D i s c o n t i n u e d * D o s a g e ( i f k n o w n ) m g m g * L e a v e D a t e D i s c o n t i n u e d b l a n k i f s t i l l t a k i n g .
D i d t h e c a s e - p a t i e n t r e c e i v e a s p i r i n o r o t h e r n o n - s t e r o i d a l a n t i - i n f l a m m a t o r y d r u g s ( N S A I D s ) ?
m Y e s m N o m U n k n o w n
I f y e s , c o m p l e t e t a b l e b e l o w
D r u g D a t e I n i t i a t e d D a t e D i s c o n t i n u e d * D o s a g e ( i f k n o w n ) m g m g * L e a v e D a t e D i s c o n t i n u e d b l a n k i f s t i l l t a k i n g .
W a s t h e c a s e - p a t i e n t a d m i t t e d t o a n i n t e n s i v e c a r e u n i t ( I C U ) ?
m Y e s m N o m U n k n o w n
D i d t h i s c a s e - p a t i e n t r e c e i v e m e c h a n i c a l v e n t i l a t i o n ?
m Y e s m N o m U n k n o w n
D i d t h e c a s e - p a t i e n t h a v e a c u t e r e s p i r a t o r y d i s t r e s s s y n d r o m e ( A R D S ) ?
m Y e s m N o m U n k n o w n
D i d t h e c a s e h a v e e n c e p h a l i t i s o r o t h e r n e u r o l o g i c c o m p l i c a t i o n s ?
m Y e s m N o m U n k n o w n
I f Y e s , p l e a s e s p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
D i d t h e c a s e h a v e m y o c a r d i t i s ?
m Y e s m N o m U n k n o w n
D i d t h e c a s e h a v e o t h e r c o m p l i c a t i o n s ?
m Y e s m N o m U n k n o w n
W h a t w a s t h e o u t c o m e f o r t h e c a s e - p a t i e n t ?
m A l i v e m D i e d m U n k n o w n
I f t h e p a t i e n t i s A L I V E , w h a t i s t h e c u r r e n t d i s p o s i t i o n o f t h e c a s e - p a t i e n t ?
m S t i l l I l l m D i s c h a r g e d t o n u r s i n g c a r e f a c i l i t y ( s p e c i f y n a m e ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
m R e c o v e r e d ( D a t e o f R e c o v e r y ) : _ _ _ _ _ ( M M D D Y Y Y Y ) m D a t e o f R e c o v e r y U n k n o w n
m O t h e r ( s p e c i f y ) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
m U n k n o w n
I f t h e p a t i e n t D I E D , p l e a s e l i s t d a t e o f d e a t h _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ( M M D D Y Y Y Y )
M e d i c a l H i s t o r y - L a b o r a t o r y a n d D i a g n o s t i c T e s t i n g
D i d t h e c a s e - p a t i e n t h a v e a c h e s t x - r a y p e r f o r m e d ?
m Y e s m N o m n o t p e r f o r m e d m U n k n o w n
D i d t h e c a s e - p a t i e n t h a v e a c h e s t C T s c a n p e r f o r m e d ?
m Y e s m N o m n o t p e r f o r m e d m U n k n o w n
I f e i t h e r t e s t w a s p e r f o r m e d , w h a t w a s t h e r e s u l t ?
m N o r m a l m A b n o r m a l m U n k n o w n
I f a b n o r m a l , w a s t h e r e e v i d e n c e o f p n e u m o n i a ?
m Y e s m N o m U n k n o w n
D i d t h e c a s e - p a t i e n t h a v e a C T s c a n / M R I o f t h e h e a d o r b r a i n ?
m Y e s m N o m n o t p e r f o r m e d m U n k n o w n
I f Y E S , w e r e t h e r e a n y a c u t e c h a n g e s ?
m Y e s m N o m U n k n o w n
I f Y e s , p l e a s e s p e c i f y : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
L i s t t h e f o l l o w i n g l a b o r a t o r y t e s t r e s u l t s U P O N i n i t i a l a d m i s s i o n :
W h i t e b l o o d c e l l ( W B C ) c o u n t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ m U n k n o w n
L y m p h o c y t e c o u n t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ m U n k n o w n
N e u t r o p h i l c o u n t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ m U n k n o w n
P l a t e l e t c o u n t _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ m U n k n o w n
D i d t h e p a t i e n t h a v e a n y o f t h e f o l l o w i n g l a b o r a t o r y a b n o r m a l i t i e s a t a n y t i m e d u r i n g t h e h o s p i t a l i z a t i o n ?
L e u k o p e n i a ( w h i t e b l o o d c e l l c o u n t < 5 , 0 0 0 l e u k o c y t e s / m m 3 )
m Y e s m N o m U n k n o w n
L y m p h o p e n i a ( t o t a l l y m p h o c y t e s < 8 0 0 / m m 3 o r l y m p h o c y t e s < 1 5 % o f t o t a l W B C )
m Y e s m N o m U n k n o w n
T h r o m b o c y t o p e n i a ( t o t a l p l a t e l e t s < 1 5 0 , 0 0 0 / m m 3 )
m Y e s m N o m U n k n o w n
W e r e b a c t e r i a l c u l t u r e s p e r f o r m e d ?
m Y e s m N o m U n k n o w n
I f Y E S , w e r e a n y p o s i t i v e ?
I f p o s i t i v e , c o m p l e t e t a b l e b e l o w
S i t e ( e g , b l o o d , C S F , p l e u r a l , s p u t u m , u r i n e ) D a t e P e r f o r m e d D a t e P o s i t i v e O r g a n i s m g r o w n
W e r e n o n - i n f l u e n z a v i r a l t e s t s p e r f o r m e d ?
m Y e s m N o m U n k n o w n
I f y e s , c o m p l e t e t a b l e b e l o w
S i t e ( e g , n a s a l a s p i r a t e , t h r o a t , B A L , b l o o d , C S F , s t o o l ) D a t e P e r f o r m e d R e s u l t O r g a n i s m
I n f l u e n z a T e s t i n g S p e c i m e n I n f o r m a t i o n
S p e c i m e n i n f o r m a t i o n
I f a n y i n f l u e n z a c u l t u r e , a n t i b o d y t e s t s , a n t i g e n d e t e c t i o n , P C R o r s p e c i a l s t a i n s w e r e p e r f o r m e d , p l e a s e n o t e r e s u l t s o f e a c h i n f l u e n z a t e s t ( i f m u l t i p l e t e s t s w e r e p e r f o r m e d p l e a s e u s e o n e l i n e p e r t e s t ) : S p e c i m e n T y p e * C o l l e c t i o n D a t e t e s t t y p e R E S U L T I n f l u e n z a t y p e / s u b t y p e S p e c i m e n I D L A B N A M E _ _ _ _ / _ _ _ _ / _ _ _ _ D F A / I F A
P C R
V i r a l C x
H I R a p i d t e s t
I m m u n o h i s t
_ _ _ _ _ _ _ _ _ _ _ _ _ P o s i t i v e
N e g a t i v e
I n d e t e r m i n a t e F l u A F l u B
F l u A / H 1 F l u A / H 3
F l u A u n s u b t y p a b l e
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L o c a l I D 1 _ _ _ _ _ _ _ _ _ _
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I m m u n o h i s t
_ _ _ _ _ _ _ _ _ _ _ _ _ P o s i t i v e
N e g a t i v e
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L o c a l I D 1 _ _ _ _ _ _ _ _ _ _
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_ _ _ _ _ _ _ _ _ _ _ _ _ P o s i t i v e
N e g a t i v e
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L o c a l I D 1 _ _ _ _ _ _ _ _ _ _
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N e g a t i v e
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* S p e c i m e n c o d e a n d t y p e :
1 . N a s o p h a r y n g e a l s w a b
2 . N a s o p h a r y n g e a l a s p i r a t e
3 . O r o p h a r y n g e a l / t h r o a t s w a b
4 . N a s a l a s p i r a t e / s w a b
5 . E n d o t r a c h e a l a s p i r a t e
6 . S e r u m 7 . B r o n c h e o a l v e o l a r l a v a g e s p e c i m e n ( B A L )
8 . S p u t u m
9 . C e r e b r o s p i n a l f l u i d ( C S F )
1 0 . T i s s u e
1 1 . S t o o l
1 2 . U r i n e 1 3 . P l e u r a l f l u i d
1 4 . P e r i t o n e a l f l u i d
1 5 . P e r i c a r d i a l f l u i d
1 6 . C h e s t f l u i d
1 7 . O t h e r
A d d i t i o n a l C o m m e n t s : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
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