ࡱ> #` abjbj5G5G dW-W-,<<<<    ___8_\` B`````uuu=??????$0hc wq<uwwc<<``m}m}m}w<` `=m}w=m}m}  m}`` 7_w8m}=0Bm}v)zvm}v m}u>#v,m}Ov$svuuucc}^uuuBwwww   1<d#   <   <<<<<< Utah Public Health Name of Local Health Department Address of Local Health Department Phone: (801) xxx-xxxx Confidential Fax (801) xxx-xxxx May14, 2008                                  ANTHRAX Patient name: ______________________________ ID: ___________ Bacillus anthracis -  PAGE 4 - ANTHRAX Bacillus anthracis This is an immediately notifiable disease CONFIDENTIAL CASE REPORT DEMOGRAPHIC INFORMATION CLINICAL INFORMATION Last Name: First Name: MI: Was patient hospitalized? Y N U Hospital: Date of admission: _____/_____/_____ to _____/_____/_____ Medical record #: Onset Date: _____/_____/_____ Clinician Name: Clinician Phone #: Phone #1: Phone #2: Phone #3: County: Zip: Date of birth: _____/_____/_____ Age: Address: City: State: Gender: (Circle one) Race: (Check all that apply) M F % White % Black/Af. Am % American Indian % Unknown % Asian % Alaskan Native % Native Hawaiian or Pacific Islander LHD Case classification: (Check one) % Confirmed % Probable % Suspect % Pending % Out of state % Not a case Ethnicity: % Hispanic % Not Hispanic % Other % Unknown Was PCR done? Y N U Name of laboratory: _____________________________ Date collected: _____/_____/_____ Type of sample: (Check all that apply) % Blood % CSF % Sterile fluid %Tissue % Stool % Swab % Other: __________________________ Test results: (Check one) % Positive - Confirmed % Inconclusive % Negative % Pending Did patient die? Y N U Date of death: _____/_____/_____ LABORATORY INFORMATION REPORTING LHD Reviewer: LHD Investigator: Phone: Date submitted to UDOH: _____/_____/_____ Reported by: (Check all that apply) % Hospital/ICP % Clinic/doctor s office % Lab % General public % Other _____________ What is the date the lab reported to the clinician? _____/_____/_____ Reporters name: _______________________________ Phone number: _______________________________ Reporters agency: ______________________________ Date reported to public health: _____/_____/_____ Syndrome (Check only one): Note: descriptions of each of these syndromes are located in the disease plan. % Cutaneous % Pulmonary/Inhalational % Gastrointestinal % Oropharyngeal Was culture done? Y N U Name of laboratory: _____________________________ Date collected: _____/_____/_____ Type of sample: (Check all that apply) % Blood % CSF % Sterile fluid %Tissue % Stool % Swab % Other: __________________________ Test results: (Check one) % Positive - Confirmed % Inconclusive % Negative % Pending Was patient treated with antibiotics: Y N U List antibiotics: ___________________________ UDOH Case classification: % Confirmed % Probable % Suspect % Pending % Out of state % Not a case List date 7 days prior to disease onset:_____/_____/_____ List date of disease onset:_____/_____/_____ For the next section (s) , obtain patients exposure history for the time period listed above Ask these questions if patient has been diagnosed with cutaneous or gastrointestinal anthrax: Does patient work in a laboratory? Y N U If yes: list name, contact information, and location of laboratory. ________________________________________________________________________________________ Does patient work with animals or animal products? (such as cattle, goats, sheep, hides, fur, wool, etc.) Y N U If yes: describe products and types of interactions: ________________________________________________ _________________________________________________________________________________________ Has patient traveled to a foreign country during the exposure period? Y N U If yes: list all countries and dates of travel: _______________________________________________________ __________________________________________________________________________________________ List patients occupation: ____________________________________________________________________________ If patient is definitely diagnosed with cutaneous anthrax and has not answered yes to one of these preceeding three questions, proceed to the inhalational exposure history. Additional notes: Was gamma phage done? Y N U UPHL or CDC Date collected: _____/_____/_____ Test results: (Check one) % Positive - Confirmed % Inconclusive % Negative % Pending Was DFA done? Y N U UPHL or CDC Date collected:_____/_____/_____ Test results: (Check one) % Positive - Confirmed % Inconclusive % Negative % Pending Patient s occupation:W]^lopŻɻwd%jh(.5CJUaJmHnHujh(.6UmHnHu hL56jhR 6UmHnHuhH7gh/6hH7ghH7g6 h56hRh6hRh56hR h6hRh5CJaJhRhj5CJaJhRh5CJaJjhUmHnHu"4W d$gdEgdV, a     " 蟘{ufufujhs6UmHnHu h maJ h1aJjhsUaJmHnHu h mhL h6)|56 jhs56UmHnHu jh!X[56UmHnHu hW56 jh56UmHnHujh(.6UmHnHu hL56 jh(.56UmHnHu% d$gdE        d$gd l $ d$a$gdys $ d$a$gd m d$gdE                   ! " $ & ' " # $ % ' ( ) * + , - / 0 2 3 5 6 8 9 : A B G H U V x ˼zzk`UQh."hQh."CJaJh."56CJaJh6fhlfHq  hh3hlhl5CJaJhQh."5CJaJh."5CJaJh8.hlhDjhDUhE_hZc aJjhq%6UmHnHujhs6UmHnHujh}u UaJmHnHu h maJjh}u 6UmHnHu' ) , . / 1 2 4 5 7 8 9 : $a$gd"&$a$gd gdQgdQ$a$gd m   + , 5 A B c d ˽qXRIhh."aJ h."aJ0h#Oh(.5@B*CJOJQJ^JaJph*h(.5@B*CJOJQJ^JaJph0h#Oh."5@B*CJOJQJ^JaJphhegh."5CJaJ hBfh."5B*CJ aJ phh."5B*CJ aJ phh."56CJaJh."5CJ aJ hDhBdmHnHujh."Uh."h8.hl   + , A B d e 0 1 T U V gd43gdrggd}u gdUfl$a$gd(.$a$gd#O$a$gd||$a$gd"&d e / 0 1 S T U V v w      2 4 6 V X p r úЫÒËÃ~~~~~~~ h."6h6h."6 h."6aJhh."aJh h."aJ hm!h  h aJh43h."aJhwh."aJ h."aJ hkUHh."h  h}u h  hBTh}u h6fh}u fHq  hKh}u h}u h."1V j > XZ\^`bgde,`gdsgdsgd43gdE_gd  & < > @ V X l n 02DFV`6Xp h'j%h(.h(. hsrh."h(=h."6 h+~h." hZdh h  he,h." hQNAhsh(=hs6 hs6hsh43h."aJh." h."6>b6T  $a$gd$ $a$gd'j%gd(.`gda|`gdWgd gda|i?<;ͬ͊͆yrngnb h."6 hZdh h  hh(.hh(.6 h(.6h(. hth." hth}u h6fh}u fHq  h}u 6h}u h+!h." hh+!h+! hhshsh."0h#Oh."5@B*CJOJQJ^JaJph*h."5@B*CJOJQJ^JaJph$  i@Pgd+~gd gdgd(.gdtdhgd}u ^`gd}u `gd}u gd}u gd+!gds&($&:<L^`$&(Z\^`vx?@Aֳֺֺֺֺֺ *h."5B*CJph *h."h."5B*CJph h."56 hwAhs hHhs hQNAhs hs6h(=hs6hshs6hs hh." hsrh."h(=h."6 h."6h." h+~h."16NPRTVXZ\^`b&(^ ^`gds`gdsgdsgd6[gdgd+~`gd(=@AklEFZ[ gdSy @ ^@ `gdSygdS$a$gdR !! !?!J!""."0"L"N"b"d"t"""""""""""2#H#J#L#x#z#########$RRĻʷʳʷʷʮʟʟʟʟʷʳʷʷʮʟʟʟʟʑU h@ZhFs& hsrh." h+~h."h(=h."6 h."6h hh!X[h."aJ h!X[aJh."hlh."56aJh."56aJh_h."aJ h."aJh."h."B*CJph6 ! 1!K!v"x"z"|"~""""""""#J#####`gdggdggd!X[gdSy#########RRR*R,R.R0R2R4R6R8R:RR@RRRSgd$a$gd44gdFs&gdg EXPOSURE HISTORY According to Agriculture  is there a concurrent outbreak in animals underway in Utah? Y N U If no, or if patient is unlikely to be tied to this outbreak, please answer the appropriate following questions: Has active surveillance been initiated to seek additional cases? Y N U If no or unknown, please explain: Parent/guardian name: Relationship: Ask these questions if patient has been diagnosed with inhalational anthrax: Travel history: Has patient spent the night away from home during the incubation period? Y N U If yes: list where and when: ____________________________________________________________ Was patient: On a cruise? Y N U Camping? Y N U In a hotel? Y N U On an airplane/train/bus? Y N U Visit tourist attractions? Y N U Touch or contact any animals or birds? Y N U Social history: Has patient been to any of the following during the incubation period: School (any grade)? Y N U Airport? Y N U Local tourist attraction? Y N U Sporting event? Y N U Gym or workout facility? Y N U Recreational water/beach? Y N U Zoo? Y N U Agricultural fair? Y N U Carnival/circus? Y N U Farm? Y N U Hunting? Y N U Pet store/animal shelter? Y N U Amusement park? Y N U Movie theater? Y N U Museums? Y N U Concert/theater/opera? Y N U Contact with animals (dead, alive)? Y N U Park or playground? Y N U Library? Y N U Street fair/farmer s market/swap meet/flea market? Y N U Casino/bingo? Y N U Party, raves, prom? Y N U Bars or clubs? Y N U Home improvement stores? Y N U Grocery store? Y N U Shopping mall? Y N U Big box retailer? (eg Walmart?) Y N U Place of worship? Y N U Healthcare provider or location? Y N U Family planning clinic? Y N U Post office? Y N U Government building? Y N U Take public transportation? 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