Form CDPH8470 "Lyme Disease Case Report" - California

What Is Form CDPH8470?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2017;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CDPH8470 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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State of California—Health and Human Services Agency
Local ID Number ___________________________
California Department of Public Health
Center for Infectious Diseases
(Please use the same ID Number on the preliminary
Division of Communicable Disease Control
and final reports to allow linkage to the same case.)
Infectious Diseases Branch
Surveillance and Statistics Section
Report Status (check one)
MS 7306, P.O. Box 997377
 Preliminary
 Final
Sacramento, CA 95899-7377
LYME DISEASE
CASE REPORT
PATIENT INFORMATION
Last Name
First Name
Middle Name
Suffix
Primary Language
 English
 Spanish
Social Security Number (9 digits)
DOB (mm/dd/yyyy)
Age
 Years
 Other:_____________________
 Months
 Days
Ethnicity (check one)
Address Number & Street - Residence
Apartment/Unit Number
 Hispanic/Latino
 Non-Hispanic/Non-Latino
 Unk
City/Town
State
Zip Code
Race*
(check all that apply, race descriptions on page 7)
Census Tract
County of Residence
Country of Residence
 African-American/Black
 American Indian or Alaska Native
Country of Birth
If not U.S. Born - Date of Arrival in U.S. (mm/dd/yyyy)
 Asian (check all that apply)
 Asian Indian
 Japanese
Home Telephone
Cellular Phone/Pager
Work/School Telephone
 Cambodian
 Korean
 Chinese
 Laotian
 Filipino
 Thai
E-mail Address
Other Electronic Contact Information
 Hmong
 Vietnamese
 Other:_____________________
Work/School Location
Work/School Contact
 Pacific Islander (check all that apply)
 Native Hawaiian
 Samoan
Gender
 Guamanian
 Male
 Female
 Other: _______________________________
 Other:_____________________
 White
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
 Yes
 No
 Unk
 Other:____________________
 Unk
Medical Record Number
Patient’s Parent/Guardian Name
*Comment: self-identity or self-reporting
Occupation Setting (see list on page 7)
Other Describe/Specify
The response to this item should be based on the
patient’s self-identity or self-reporting. Therefore,
patients should be offered the option of selecting
Occupation (see list on page 7)
Other Describe/Specify
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
Page 1 of 7
CDPH 8470 (revised 02/17)
State of California—Health and Human Services Agency
Local ID Number ___________________________
California Department of Public Health
Center for Infectious Diseases
(Please use the same ID Number on the preliminary
Division of Communicable Disease Control
and final reports to allow linkage to the same case.)
Infectious Diseases Branch
Surveillance and Statistics Section
Report Status (check one)
MS 7306, P.O. Box 997377
 Preliminary
 Final
Sacramento, CA 95899-7377
LYME DISEASE
CASE REPORT
PATIENT INFORMATION
Last Name
First Name
Middle Name
Suffix
Primary Language
 English
 Spanish
Social Security Number (9 digits)
DOB (mm/dd/yyyy)
Age
 Years
 Other:_____________________
 Months
 Days
Ethnicity (check one)
Address Number & Street - Residence
Apartment/Unit Number
 Hispanic/Latino
 Non-Hispanic/Non-Latino
 Unk
City/Town
State
Zip Code
Race*
(check all that apply, race descriptions on page 7)
Census Tract
County of Residence
Country of Residence
 African-American/Black
 American Indian or Alaska Native
Country of Birth
If not U.S. Born - Date of Arrival in U.S. (mm/dd/yyyy)
 Asian (check all that apply)
 Asian Indian
 Japanese
Home Telephone
Cellular Phone/Pager
Work/School Telephone
 Cambodian
 Korean
 Chinese
 Laotian
 Filipino
 Thai
E-mail Address
Other Electronic Contact Information
 Hmong
 Vietnamese
 Other:_____________________
Work/School Location
Work/School Contact
 Pacific Islander (check all that apply)
 Native Hawaiian
 Samoan
Gender
 Guamanian
 Male
 Female
 Other: _______________________________
 Other:_____________________
 White
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
 Yes
 No
 Unk
 Other:____________________
 Unk
Medical Record Number
Patient’s Parent/Guardian Name
*Comment: self-identity or self-reporting
Occupation Setting (see list on page 7)
Other Describe/Specify
The response to this item should be based on the
patient’s self-identity or self-reporting. Therefore,
patients should be offered the option of selecting
Occupation (see list on page 7)
Other Describe/Specify
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
Page 1 of 7
CDPH 8470 (revised 02/17)
California Department of Public Health
LYME DISEASE CASE REPORT
First three letters of
patient’s last name:
SIGNS AND SYMPTOMS
Symptomatic?
Onset Date (mm/dd/yyyy)
Date First Sought Medical Care (mm/dd/yyyy)
Duration of Acute Symptoms (days)
 Yes  No  Unk
Signs and Symptoms
Yes
No
Unk
If Yes, Specify as Noted
Onset date (mm/dd/yyyy)
Location on body
EM size at examination, diameter (cm)
Erythema migrans (EM)
Brief recurrent attacks of
Onset date (mm/dd/yyyy)
Joint(s) affected
swelling in one or a few joints
Chronic progressive arthritis
Onset date (mm/dd/yyyy)
not preceded by brief attacks
Facial (VII) palsy or other
Onset date (mm/dd/yyyy)
cranial neuropathy
Onset date (mm/dd/yyyy)
Radiculoneuropathy
Onset date (mm/dd/yyyy)
Paresthesias, dysesthesias
Onset date (mm/dd/yyyy)
Lymphocytic meningitis
Onset date (mm/dd/yyyy)
Encephalomyelitis
Second or third degree
Onset date (mm/dd/yyyy)
atrioventricular block
Other signs / symptoms (specify)
Onset date (mm/dd/yyyy)
PAST MEDICAL HISTORY
Prior Lyme disease diagnosis?
Specify diagnosis date(s) (mm/dd/yyyy)
 Yes
 No
 Unk
PAST MEDICAL HISTORY - OTHER
Specify
HOSPITALIZATION
Did patient visit emergency room for illness?
Was patient hospitalized?
If Yes, how many total hospital nights?
 Yes  No  Unk
 Yes
 No
 Unk
If there were any ER or hospital stays related to this illness, specify details below.
HOSPITALIZATION - DETAILS
Hospital Name 1
Street Address
Admit Date (mm/dd/yyyy)
City
Discharge / Transfer Date (mm/dd/yyyy)
State
Zip Code
Telephone Number
Medical Record Number
Discharge Diagnosis
Hospital Name 2
Street Address
Admit Date (mm/dd/yyyy)
City
Discharge / Transfer Date (mm/dd/yyyy)
State
Zip Code
Telephone Number
Medical Record Number
Discharge Diagnosis
Page 2 of 7
CDPH 8470 (revised 02/17)
California Department of Public Health
LYME DISEASE CASE REPORT
First three letters of
patient’s last name:
TREATMENT / MANAGEMENT
Received treatment?
If Yes, specify the treatments below.
 Yes  No  Unk
TREATMENT / MANAGEMENT DETAILS
Treatment Type 1
If Antibiotic, specify route
Treatment Name
Date Started (mm/dd/yyyy)
Date Ended (mm/dd/yyyy)
 Antibiotic
 Other
Treatment Type 2
If Antibiotic, specify route
Treatment Name
Date Started (mm/dd/yyyy)
Date Ended (mm/dd/yyyy)
 Antibiotic
 Other
LABORATORY INFORMATION
(Copies of laboratory reports must be included with case history.)
LABORATORY RESULTS SUMMARY
Specimen Type
Collection Date (mm/dd/yyyy)
Laboratory Name
Telephone Number
Type of Test
Specify Test Results as Noted
EIA / IFA
Antibody
Specify titre or OD value
Interpretation
 EIA
 IFA
 Not done
 IgG
 IgM
 Total
 Unspecified
 Positive
 Negative
 Equivocal
 Other:_____________
 Unknown
 Pending
IgG Western Immunoblot
Specify Bands Present
Interpretation
 Done
 Not done
 18-20
 21-24
 28
 30
 35
 39
 41
 45
 58
 66
 Positive
 Negative
 Equivocal
 88
 93
 Unknown
 Pending
IgM Western Immunoblot
Specify Bands Present
Interpretation
 Done
 Not done
 18-20
 21-24
 28
 30
 35
 39
 41
 45
 58
 66
 Positive
 Negative
 Equivocal
 88
 93
 Unknown
 Pending
Specify Test(s)
Result(s)
Other test
EPIDEMIOLOGIC INFORMATION
INCUBATION PERIOD: 30 DAYS PRIOR TO ILLNESS ONSET
EXPOSURES/RISK FACTORS
DID THE PATIENT PARTICIPATE IN ANY OUTDOOR ACTIVITIES IN WOODED, BRUSHY, OR GRASSY AREAS DURING THE INCUBATION PERIOD?
Outdoor Activity 1
Describe Activity
 Hiking, camping, picnicking
 Other recreational
Location
Date (mm/dd/yyyy)
 Occupational / non-recreational
Outdoor Activity 2
Describe Activity
 Hiking, camping, picnicking
 Other recreational
Location
Date (mm/dd/yyyy)
 Occupational / non-recreational
Outdoor Activity 3
Describe Activity
 Hiking, camping, picnicking
 Other recreational
Location
Date (mm/dd/yyyy)
 Occupational / non-recreational
EXPOSURES/RISK FACTORS - TICK BITE
Tick bite during incubation period?
If Yes, describe
Date Noticed (mm/dd/yyyy)
 Yes
 No
 Unk
Where (county, habitat)?
Where (anatomic)?
Approximate Duration of Attachment
Page 3 of 7
CDPH 8470 (revised 02/17)
California Department of Public Health
LYME DISEASE CASE REPORT
First three letters of
patient’s last name:
NOTES / REMARKS
REPORTING AGENCY
Investigator Name
Local Health Jurisdiction
Telephone Number
Date (mm/dd/yyyy)
Date First Reported to Public Health (mm/dd/yyyy)
First Reported by
 Clinician
 Laboratory
 Other (specify): ________________
EPIDEMIOLOGICAL LINKAGE
Epi-linked to known case?
Contact Name / Case Number
 Yes
 No
 Unk
DISEASE CASE CLASSIFICATION
Case Classification (see case definition on page 6)
 Confirmed
 Probable
 Suspected
STATE USE ONLY
State Case Classification
 Confirmed
 Probable
 Suspected
 Not a case
 Need additional information
Page 4 of 7
CDPH 8470 (revised 02/17)
California Department of Public Health
LYME DISEASE CASE REPORT
CASE DEFINITION
LYME DISEASE (2017)
CLINICAL DESCRIPTION
A systemic, tick-borne disease with protean manifestations, including dermatologic, rheumatologic, neurologic, and cardiac abnormalities. The most
common clinical marker for the disease is erythema migrans (EM), the initial skin lesion that occurs in 60%-80% of patients.
For purposes of surveillance, EM is defined as a skin lesion that typically begins as a red macule or papule and expands over a period of days to weeks
to form a large round lesion, often with partial central clearing. A single primary lesion must reach greater than or equal to 5 cm in size across its largest
diameter. Secondary lesions also may occur. Annular erythematous lesions occurring within several hours of a tick bite represent hypersensitivity reactions
and do not qualify as EM. For most patients, the expanding EM lesion is accompanied by other acute symptoms, particularly fatigue, fever, headache, mildly
stiff neck, arthralgia, or myalgia. These symptoms are typically intermittent. The diagnosis of EM must be made by a physician. Laboratory confirmation is
recommended for persons with no known exposure.
For purposes of surveillance, late manifestations include any of the following when an alternate explanation is not found:
● Musculoskeletal system: Recurrent, brief attacks (weeks or months) of objective joint swelling in one or a few joints, sometimes followed by chronic
arthritis in one or a few joints. Manifestations not considered as criteria for diagnosis include chronic progressive arthritis not preceded by brief attacks
and chronic symmetrical polyarthritis. Additionally, arthralgia, myalgia, or fibromyalgia syndromes alone are not criteria for musculoskeletal involvement.
● Nervous system: Any of the following signs that cannot be explained by any other etiology, alone or in combination: lymphocytic meningitis; cranial
neuritis, particularly facial palsy (may be bilateral); radiculoneuropathy; or, rarely, encephalomyelitis. Headache, fatigue, paresthesia, or mildly stiff neck
alone, are not criteria for neurologic involvement.
● Cardiovascular system: Acute onset of high-grade (2
-degree or 3
-degree) atrioventricular conduction defects that resolve in days to weeks and
nd
rd
are sometimes associated with myocarditis. Palpitations, bradycardia, bundle branch block, or myocarditis alone are not criteria for cardiovascular
involvement.
LABORATORY CRITERIA FOR DIAGNOSIS
For the purposes of surveillance, laboratory evidence includes:
● A positive culture for B. burgdorferi, OR
● A positive two-tier test. (This is defined as a positive or equivocal enzyme immunoassay (EIA) or immunofluorescent assay (IFA) followed by a positive
Immunoglobulin M
(IgM) or Immunoglobulin G
(IgG) western immunoblot (WB) for Lyme disease), OR
1
2
● A positive single-tier IgG
WB test for Lyme disease
.
2
3
1
IgM WB is considered positive when at least two of the following three bands are present: 24 kilodalton (kDa) outer surface protein C (OspC)*, 39 kDa
basic membrane protein A (BmpA), and 41 kDa (Fla). Disregard IgM results for specimens collected >30 days after symptom onset.
2
IgG WB is considered positive when at least five of the following 10 bands are present: 18 kDa, 24 kDa (OspC)*, 28 kDa, 30 kDa, 39 kDa (BmpA),
41 kDa flagellin (Fla), 45 kDa, 58 kDa (not GroEL), 66 kDa, and 93 kDa.
3
While a single IgG WB is adequate for surveillance purposes, a two-tier test is still recommended for patient diagnosis.
*Depending upon the assay, OspC could be indicated by a band of 21, 22, 23, 24 or 25 kDa.
CRITERIA TO DISTINGUISH A NEW CASE FROM AN EXISTING CASE
Case not previously reported to public health authorities.
EXPOSURE
Exposure is defined as having been (less than or equal to 30 days before onset of EM) in wooded, brushy, or grassy areas (i.e., potential tick habitats)
of Lyme disease vectors. Since infected ticks are not uniformly distributed, a detailed travel history to verify whether exposure occurred in a high or low
incidence state is needed. An exposure in a high-incidence state is defined as exposure in a state with an average Lyme disease incidence of at least
10 confirmed cases/100,000 for the previous three reporting years. A low-incidence state is defined as a state with a disease incidence of <10 confirmed
cases/100,000. (see https://www.cdc.gov/lyme/stats/tables.html). A history of tick bite is not required.
(continued on page 6)
Page 5 of 7
CDPH 8470 (revised 02/17)
Page of 7