Form CDPH8687 "West Nile Virus (Wnv) Infection Case Report" - California

What Is Form CDPH8687?

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 April 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 CDPH8687 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 CDPH8687 "West Nile Virus (Wnv) Infection Case Report" - California

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California Department of Public Health
State of California - Health and Human Services Agency
West Nile Virus (WNV) Infection Case Report
Date Form Completed:
/
/
.
Patient Information:
Last Name: _____________________ First Name:
DOB:___/___/___ Age:
Med Rec #: __________
Address: _________________________________________ City: __________________________ Zip Code: __________
Phone: Home (______)________________ Work (______)________________ Occupation: _________________________
Sex:
Male
Ethnicity:
Hispanic
Race:
White
Asian/ Pacific Islander
Female
Non-Hispanic
Black
American Indian/Alaskan Native
Unknown
Unknown
Unknown
Other: ______________________
Physician Information (Mandatory):
Name: ________________________________________ Facility: ______________________________________________
Pager/Phone: (______)_________________ Fax: (______)_________________ Email: ___________________________
Date of first symptom(s):____/____/____
Hospitalized or
ER / Outpatient
If hospitalized, admit date: ____/____/____ Discharge date: ____/____/____ If patient died, date of death: ____/____/____
Travel/Exposures within 4 wks of onset (specify details):
Clinical syndrome:
Mosquito bites/exposure ……….…
Yes
No
Unk
Encephalitis ………………
Yes
No
Unk
_____________________________________
Dates/Locations:
Aseptic meningitis ……….
Yes
No
Unk
Travel outside of California …….…
Yes
No
Unk
Acute flaccid paralysis ….
Yes
No
Unk
_____________________________________
Dates/Locations:
Febrile illness ………..…..
Yes
No
Unk
Travel outside the U.S. …….……..
Yes
No
Unk
_____________________________________
Asymptomatic ……………
Dates/Locations:
Yes
No
Unk
Donated blood …………………….
Yes
No
Unk
Other ________________________________________
____/____/____
Date:
Do the following apply anytime during current illness:
Donated organ …………………….
Yes
No
Unk
In ICU ……………………..
Yes
No
Unk
____/____/____
Date:
Fever 38°C..…………….
Received blood transfusion ………
Yes
No
Unk
Yes
No
Unk
____/____/____
Date:
Headache ………………...
Yes
No
Unk
Received organ transplant: ………
Yes
No
Unk
Rash ………………………
Yes
No
Unk
____/____/____
Date:
Currently pregnant ………………..
Yes
No
Unk
Stiff neck ………………….
Yes
No
Unk
____
Week of gestation:
Muscle pain/weakness ….
Yes
No
Unk
Ever traveled outside the U.S. ….
Yes
No
Unk
Altered consciousness ….
Yes
No
Unk
____________________________________
Dates/Locations:
Seizures ………………….
Yes
No
Unk
Ever rec’d yellow fever vaccine.....
Yes
No
Unk
____/____/____
Date:
CSF Results
CBC Results
Date: ____/____/____
Date: ____/____/____
Knowledge of WNV prior to illness:
RBC: ____
WBC: ____
Did patient do anything to avoid mosquito bites?
WBC: ____
%Diff: _____________
If yes,
Yes
No
Unk
%Diff: ______________
HCT: ____
- used insect repellent?
Yes
No
Unk
Protein: ____
Plt: ____
- drained standing water near home?
Yes
No
Unk
Glucose: ____
Other lab results (MRI/CT, LFTs, etc.): ______________
Other significant history/exposures: ___________________
_______________________________________________
___________________________________________________
Past medical history:
Other lab results (MRI/CT, etc.): _______________________
Hypertension:
Yes
No
Unk
___________________________________________________
Diabetes Type ________
Yes
No
Unk
West Nile Virus Test Results:
________________ _____________ ___/___/___ _________ ___________
Other: _________________________________________
Testing Laboratory Specimen Type
Coll Date
Test Type
Result
________________ _____________ ___/___/___ _________ ___________
Testing Laboratory Specimen Type
Coll Date
Test Type
Result
FAX this form: (510) 412-6263
or MAIL to: CDPH/Vector Borne Disease Section, 850 Marina Bay Parkway, Richmond CA 94804
CDPH 8687 (04/17)
California Department of Public Health
State of California - Health and Human Services Agency
West Nile Virus (WNV) Infection Case Report
Date Form Completed:
/
/
.
Patient Information:
Last Name: _____________________ First Name:
DOB:___/___/___ Age:
Med Rec #: __________
Address: _________________________________________ City: __________________________ Zip Code: __________
Phone: Home (______)________________ Work (______)________________ Occupation: _________________________
Sex:
Male
Ethnicity:
Hispanic
Race:
White
Asian/ Pacific Islander
Female
Non-Hispanic
Black
American Indian/Alaskan Native
Unknown
Unknown
Unknown
Other: ______________________
Physician Information (Mandatory):
Name: ________________________________________ Facility: ______________________________________________
Pager/Phone: (______)_________________ Fax: (______)_________________ Email: ___________________________
Date of first symptom(s):____/____/____
Hospitalized or
ER / Outpatient
If hospitalized, admit date: ____/____/____ Discharge date: ____/____/____ If patient died, date of death: ____/____/____
Travel/Exposures within 4 wks of onset (specify details):
Clinical syndrome:
Mosquito bites/exposure ……….…
Yes
No
Unk
Encephalitis ………………
Yes
No
Unk
_____________________________________
Dates/Locations:
Aseptic meningitis ……….
Yes
No
Unk
Travel outside of California …….…
Yes
No
Unk
Acute flaccid paralysis ….
Yes
No
Unk
_____________________________________
Dates/Locations:
Febrile illness ………..…..
Yes
No
Unk
Travel outside the U.S. …….……..
Yes
No
Unk
_____________________________________
Asymptomatic ……………
Dates/Locations:
Yes
No
Unk
Donated blood …………………….
Yes
No
Unk
Other ________________________________________
____/____/____
Date:
Do the following apply anytime during current illness:
Donated organ …………………….
Yes
No
Unk
In ICU ……………………..
Yes
No
Unk
____/____/____
Date:
Fever 38°C..…………….
Received blood transfusion ………
Yes
No
Unk
Yes
No
Unk
____/____/____
Date:
Headache ………………...
Yes
No
Unk
Received organ transplant: ………
Yes
No
Unk
Rash ………………………
Yes
No
Unk
____/____/____
Date:
Currently pregnant ………………..
Yes
No
Unk
Stiff neck ………………….
Yes
No
Unk
____
Week of gestation:
Muscle pain/weakness ….
Yes
No
Unk
Ever traveled outside the U.S. ….
Yes
No
Unk
Altered consciousness ….
Yes
No
Unk
____________________________________
Dates/Locations:
Seizures ………………….
Yes
No
Unk
Ever rec’d yellow fever vaccine.....
Yes
No
Unk
____/____/____
Date:
CSF Results
CBC Results
Date: ____/____/____
Date: ____/____/____
Knowledge of WNV prior to illness:
RBC: ____
WBC: ____
Did patient do anything to avoid mosquito bites?
WBC: ____
%Diff: _____________
If yes,
Yes
No
Unk
%Diff: ______________
HCT: ____
- used insect repellent?
Yes
No
Unk
Protein: ____
Plt: ____
- drained standing water near home?
Yes
No
Unk
Glucose: ____
Other lab results (MRI/CT, LFTs, etc.): ______________
Other significant history/exposures: ___________________
_______________________________________________
___________________________________________________
Past medical history:
Other lab results (MRI/CT, etc.): _______________________
Hypertension:
Yes
No
Unk
___________________________________________________
Diabetes Type ________
Yes
No
Unk
West Nile Virus Test Results:
________________ _____________ ___/___/___ _________ ___________
Other: _________________________________________
Testing Laboratory Specimen Type
Coll Date
Test Type
Result
________________ _____________ ___/___/___ _________ ___________
Testing Laboratory Specimen Type
Coll Date
Test Type
Result
FAX this form: (510) 412-6263
or MAIL to: CDPH/Vector Borne Disease Section, 850 Marina Bay Parkway, Richmond CA 94804
CDPH 8687 (04/17)