Form CDPH8548 "Q Fever Case Report" - California

What Is Form CDPH8548?

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 January 1, 2015;
  • 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 CDPH8548 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form CDPH8548 "Q Fever Case Report" - California

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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
Q FEVER
CASE REPORT
PATIENT INFORMATION
Primary Language
Last Name
First Name
Middle Name
Suffix
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 9)
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
Other: _______________________________
Male
Female
Other:_____________________
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
White
Yes
No
Unk
Other:____________________
Medical Record Number
Patient’s Parent/Guardian Name
Unk
*Comment: self-identity or self-reporting
Occupation Setting (see list on page 9)
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 9)
Other Describe/Specify
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
Page 1 of 9
CDPH 8548 (revised 01/15)
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
Q FEVER
CASE REPORT
PATIENT INFORMATION
Primary Language
Last Name
First Name
Middle Name
Suffix
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 9)
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
Other: _______________________________
Male
Female
Other:_____________________
Pregnant?
If Yes, Est. Delivery Date (mm/dd/yyyy)
White
Yes
No
Unk
Other:____________________
Medical Record Number
Patient’s Parent/Guardian Name
Unk
*Comment: self-identity or self-reporting
Occupation Setting (see list on page 9)
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 9)
Other Describe/Specify
more than one racial designation.
CLINICAL INFORMATION
Physician Name - Last Name
First Name
Telephone Number
Page 1 of 9
CDPH 8548 (revised 01/15)
California Department of Public Health
Q FEVER 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)
Yes No Unk
Signs and Symptoms
Yes
No
Unk
If Yes, Specify as Noted
Highest temperature (specify °F/°C)
Fever
Myalgia
Rigors, shaking chills
Malaise
Location
Rash
Cough
Severe retrobulbar headache
Splenomegaly
Hepatomegaly
Pneumonia
Hepatitis
Endocarditis
Osteomyelitis, osteoarthritis
Abdominal pain
Findings
Abnormal chest x-ray
Specify
Elevated liver enzyme levels
Thrombocytopenia
Other signs / symptoms (specify)
PAST MEDICAL HISTORY
Immunocompromised?
If Yes, specify condition
Yes No Unk
Valvular heart disease?
Yes No Unk
Prior Q fever diagnosis?
If Yes, specify date
Yes No Unk
Chronic kidney disease?
If Yes, specify condition
Yes No Unk
Pregnancy?
Yes No Unk
Other (specify)
Page 2 of 9
CDPH 8548 (revised 01/15)
California Department of Public Health
Q FEVER CASE REPORT
First three letters of
patient’s last name:
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
TREATMENT / MANAGEMENT
Received treatment?
If Yes, specify the treatments below.
Yes No Unk
TREATMENT / MANAGEMENT DETAILS
Treatment Type 1
Treatment Name
Date Started (mm/dd/yyyy)
Date Ended (mm/dd/yyyy)
Antibiotic Other
Treatment Type 2
Treatment Name
Date Started (mm/dd/yyyy)
Date Ended (mm/dd/yyyy)
Antibiotic Other
OUTCOME
Outcome?
If Survived,
Date of Death (mm/dd/yyyy)
Survived as of ________________________________(mm/dd/yyyy)
Survived Died Unk
LABORATORY INFORMATION
LABORATORY RESULTS SUMMARY - SERUM
Specimen Type 1
Type of Test
Test Phase
Antibody Type
Collection Date (mm/dd/yyyy)
Serum (acute)
Phase I
Phase II
IFA
CF
ELISA
MAT
IgM IgG
Serum (convalescent)
C. burnetii Quantitative Result
Specify Result Unit
Interpretation
Titer
O.D.
Positive
Negative
Equivocal
Laboratory Name
Telephone Number
Specimen Type 2
Type of Test
Collection Date (mm/dd/yyyy)
Test Phase
Antibody Type
Serum (acute)
Phase I
Phase II
IFA
CF
ELISA
MAT
IgM IgG
Serum (convalescent)
C. burnetii Quantitative Result
Specify Result Unit
Interpretation
Titer
O.D.
Positive
Negative
Equivocal
Laboratory Name
Telephone Number
Specimen Type 3
Type of Test
Collection Date (mm/dd/yyyy)
Test Phase
Antibody Type
Serum (acute)
Phase I
Phase II
IFA
CF
ELISA
MAT
IgM IgG
Serum (convalescent)
C. burnetii Quantitative Result
Specify Result Unit
Interpretation
Titer
O.D.
Positive
Negative
Equivocal
Laboratory Name
Telephone Number
Page 3 of 9
CDPH 8548 (revised 01/15)
California Department of Public Health
Q FEVER CASE REPORT
First three letters of
patient’s last name:
LABORATORY RESULTS SUMMARY - OTHER
Specimen Type 1
If Clinical specimen, specify
Type of Test
Collection Date (mm/dd/yyyy)
Blood
Culture
PCR
Immunostain
Clinical specimen
Interpretation
Laboratory Name
Telephone Number
Specimen Type 2
If Clinical specimen, specify
Type of Test
Collection Date (mm/dd/yyyy)
Blood
Culture
PCR
Immunostain
Clinical specimen
Interpretation
Laboratory Name
Telephone Number
IMAGING SUMMARY
Anatomic Site
Date (mm/dd/yyyy)
Type of Imaging
X-ray
CT
MRI
Other:________________________
Result
Interpretation
Facility Name
Telephone Number
EPIDEMIOLOGIC INFORMATION
INCUBATION PERIOD: 2 MONTHS PRIOR TO ILLNESS ONSET
FOOD HISTORY
DID THE PATIENT EAT OR DRINk ANY OF THE FOLLOwING ITEMS DURING THE INCUBATION PERIOD?
Food Item
Yes
No
Unk
If Yes, Specify as Noted
Animal species and source
Unpasteurized milk
Animal species and source
Other unpasteurized dairy product
Other (specify)
ANIMAL EXPOSURES
DID THE PATIENT HAVE CONTACT wITH ANY OF THE FOLLOwING ANIMALS DURING THE INCUBATION PERIOD?
Exposure
Yes
No
Unk
If Yes, Specify as Noted
Animal species and location
Birthing animals or birth products
Exposure and geographic location
Cattle
Exposure and geographic location
Sheep
Exposure and geographic location
Goats
Exposure and geographic location
Pigeons
Exposure and geographic location
Rabbits
Exposure and geographic location
Cats
Other (specify animal exposure and location)
Page 4 of 9
CDPH 8548 (revised 01/15)
California Department of Public Health
Q FEVER CASE REPORT
First three letters of
patient’s last name:
OCCUPATIONAL / RECREATIONAL EXPOSURES
wAS PATIENT EMPLOYED IN (OR SPEND SIGNIFICANT TIME IN) ANY OF THE FOLLOwING ACTIVITIES DURING THE INCUBATION PERIOD?
Exposure
Yes
No
Unk
If Yes, Specify as Noted
Location
Wool or felt plant
Location
Tannery or rendering plant
Animal species and location
Veterinary medicine
Animal species and location
Medical research
Animal species and location
Animal research
Location
Microbiology laboratory
Animal species and location
Dairy
Animal species and location
Slaughterhouse
Animal species and location
Animal farm / ranch
Live in household with person
Occupation
occupationally related to above
Other (specify exposure and geographic location)
TRAVEL HISTORY (INCUBATION PERIOD IS 2 MONTHS PRIOR TO ILLNESS ONSET)
Did patient travel outside county of residence during the incubation period?
If Yes, specify all locations and dates below.
Yes No Unk
TRAVEL HISTORY - DETAILS
Location (city, county, state, country)
Date Travel Started (mm/dd/yyyy)
Date Travel Ended (mm/dd/yyyy)
ILL CONTACTS
Any contacts with similar illness (including household contacts)?
If Yes, specify details below.
Yes No Unk
ILL CONTACTS - DETAILS
Name 1
Age
Gender
Telephone Number
Type of Contact / Relationship
Date of Contact (mm/dd/yyyy)
Street Address
Exposure Event
Illness Onset Date (mm/dd/yyyy)
City
State
Zip Code
Date First Reported to Public Health (mm/dd/yyyy)
(continued on page 6)
Page 5 of 9
CDPH 8548 (revised 01/15)