Download Patient Information

Case Report # ________________
Smallpox Case Investigation Supplementary (Form 1B)
Patient Information
STATE
1. DATE OF FOLLOW-UP:
Month
Day
Year
2. NAME OF PERSON FILING THIS CASE:
Last: __________________________ ___ ___First: _________________________________ Middle Initial: ____
3. PATIENT’S NAME:
Last: ________________________________ First: _________________________________ Middle Name: _________________________ Suffix: _________ Nickname: _________________
Yes
4. ADMITTED TO 2ND HOSPITAL OR ISOLATION SITE?
No
Unknown
IF YES, DATE OF ADMISSION:
Month
Day
Year
HOSPITAL NAME:
2nd HOSPITAL MEDICAL RECORD #: ________________________
City
State
Clinical Course
5. SMALLPOX TYPES*: RASH (MOST SEVERE STAGE):
Ordinary Type:
Modified Type
Flat Type
Hemorrhagic Type:
Confluent – Face and other site
Semi-confluent – Face only
Early
Late
*Ordinary type:
Confluent
Semi-confluent
Discrete
Raised, pustular lesions with 3 sub-types:
Confluent rash on face and forearms
Confluent rash on face, discrete elsewhere
Areas of normal skin between pustules, even on face
Modified type:
Like ordinary type but with an accelerated course
Discrete lesions
Flat type:
Hemorrhagic type:
Early
Late
Pustules remain flat; usually confluent or semi-confluent, usually fatal
Widespread hemorrhages in skin and mucous membranes
With purpuric rash, always fatal
With hemorrhage into base pustules, usually fatal
6. DATE LAST SCAB FELL OFF:
Month
Day
7. COMPLICATIONS (Check all that apply).
Skin Secondary bacterial infection:
Ocular corneal ulcer or keratitis:
CNS encephalitis:
Respiratory:
Respiratory:
Joint/Bones:
Joint/Bones:
Bronchitis
Pneumonia
Arthralgia
Osteitis
Year
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Yes
No
Unknown
Hemorrhagic:
Shock:
Other, please specify: ____________________________________________________
8. ANTIVIRAL MEDICATION: CIDOFOVIR
OTHER ANTIVIRAL MEDICATIONS, SPECIFY: ______________________________________________________________________________________
9. SMALLPOX VACCINATION HISTORY
WAS THE CASE VACCINATED SINCE THE COMPLETION OF FORM 1A?
DATE:
VACCINE “TAKE” RECORDED AT 7 DAYS?
Month
Day
Yes
Yes
No
No
Unknown
Unknown
Year
Clinical Course Disposition
10. DATE OF HOSPITAL DISCHARGE:
Month
COMPLICATIONS AT DISCHARGE:
Day
Yes
Year
No
Unknown
IF YES, PLEASE SPECIFY: _____________________________________________________________________________________________________
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Draft Version 4.1 31 Dec 01