Case Report Form

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1、Swine Influenza Case Report Form (FAX to: 404-657-7517)State EPI ID # (epidemiology ID) _CDC EPI ID # _State lab specimen ID #1 _CDC lab specimen ID #1 _State lab specimen ID #2 _CDC lab specimen ID #2 _CDC (lab) unique ID # _Reported by:State: _ County: _ Date reported to state/local health departm

2、ent_/_/_Name of Person Reporting to CDC: Last Name: _ First Name: _ Phone Number :( )_-_ Fax Number :( )_-_ E-Mail: _At the time of this report, is the case: Probable Confirmed (please see: www.cdc.gov/swineflu for case definitions)Patient Demographic Data:Date of Birth (mm/dd/yy): _/_/_Race: Americ

3、an Indian/Alaska NativeWhite Asian Black Native Hawaiian/Other Pacific Islander MultiracialEthnicity: Hispanic Non-HispanicSex: Male Female If Female, is the patient pregnant? Yes (weeks pregnant)_ No UnknownClinical Data:Date of symptom onset (mm/dd/yy): _/_/_Signs and symptoms: (check all that app

4、ly) Fever 37.8 C (100 F) _T max Sore throat Feverish but temperature not taken Conjunctivitis Cough Shortness of breath Headache Diarrhea Seizures Vomiting Rhinorrhea Other, specify _Was the patient hospitalized? Yes No UnknownWas the patient admitted to the intensive case unit? Yes No UnknownDid th

5、e patient require mechanical ventilation? Yes No UnknownDid the patient die as a result of this illness? Yes No UnknownMedical History:Did the case-patient receive influenza vaccine between September 2008 and March 2009? Yes No Dont KnowIf yes: Number of doses: 1 Date (mm/dd/yy) _/_/_If day unknown

6、use 15 Type of vaccine: Inactivated (injectable) Live Attenuated (spray) Unknown 2 Date (mm/dd/yy) _/_/_If day unknown use 15Type of vaccine: Inactivated (injectable) Live Attenuated (spray) UnknownDoes the case-patient have any of the following?a.Asthma yes no unknown b. Other chronic lung disease

7、yes no unknown c. Chronic heart or circulatory disease yes no unknownd. Metabolic disease (incl diabetes mellitus) yes no unknown e. Kidney disease yes no unknownf. Cancer in the last 12 months yes no unknowng. Immunosuppressive condition (HIV infection, chronic corticosteroid therapy, or organ tran

8、splant recipient) yes no unknownh. Other chronic diseases yes no unknowni. Neurological disease yes no unknownDiagnostic Findings:General testsLeukopenia(white blood cell count 5,000 leukocytes/mm3) Yes No UnknownLymphopenia (total lymphocytes 800/mm3 or lymphocytes 15% of total WBC) Yes No UnknownT

9、hrombocytopenia (total platelets 37.8C or 100 FCoughSore throatRunny noseDiarrheaOnset date1_/_/20092_/_/20093_/_/20094_/_/20095_/_/20096_/_/20097_/_/20098_/_/20099_/_/200910_/_/2009*Use to complete the relationship of the household member to the patient: 1=spouse, 2=mother, 3=father, 4=child, 5=sister, 6=brother, 7=cousin, 8=aunt, 9=uncle, 10=grandmother, 11=grandfather, 12=not related, 19=otherIf any of the patients household members been tested for influenza, please complete contact tracing form for each household member.* Please refer to www.cdc.gov/swineflu for case definitionV3.050109