Form PD-16 "Universal Reporting Form" - New York City

What Is Form PD-16?

This is a legal form that was released by the New York City Department of Health and Mental Hygiene - a government authority operating within New York City. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the New York City Department of Health and Mental Hygiene;
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  • Quick to customize;
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  • Fill out the form in our online filing application.

Download a fillable version of Form PD-16 by clicking the link below or browse more documents and templates provided by the New York City Department of Health and Mental Hygiene.

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Download Form PD-16 "Universal Reporting Form" - New York City

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New York City Department of Health and Mental Hygiene
Universal Reporting Form
To report an immediately notifiable disease or condition, an outbreak among three or more persons or an unusual manifestation of any disease or
condition, or any newly apparent or emerging disease or syndrome, call the Provider Access Line at 866-692-3641.
Diseases and conditions in green and marked with * are immediately notifable; those marked with † are immediately notifiable if case meets the risk
group criteria on page 2. Report by calling 866-692-3641.
For all other diseases and conditions, report using Reporting Central online via NYCMED at www.nyc.gov/health/nycmed, mail this form to the NYC
Department of Health and Mental Hygiene, 42-09 28 th Street, CN-22, Long Island City, NY 11101, or call 866-692-3641 for the appropriate fax number.
Go to www.nyc.gov/health/diseasereporting for more information.
Patient Information
Patient Last Name
First Name
Middle Name
DATE OF REPORT
Patient AKA: Last Name
AKA: First Name
AKA: Middle Name
_______ /_______ /_______
Age
Date of Birth
Country of Birth
Social Security Number
DATE OF DIAGNOSIS
_______ /_______ /_______
If patient is a child, Guardian Last Name
Guardian First Name
Guardian Middle Name
_______ /_______ /_______
Medicaid Number
Medical Record Number
DATE OF ILLNESS ONSET
Patient Home Address
City
State
Zip Code
_______ /_______ /_______
Country
Borough:
Manhattan
Bronx
Brooklyn
Queens
Staten Island
Unknown
Not NYC
M
M
M
M
M
M
M
Email Address
Mobile Phone
Home Phone
Homeless
M
Sex
Male
Transgender MTF
Race
Black
American Indian/Alaska Native
Asian
Ethnicity
Hispanic
M
M
M
M
M
M
r
Unknown
Female
Transgender FTM
Unknown
White
Native Hawaiian/Pacific Islande
Other: _____________________
Unknown
Non-Hispanic
M
M
M
M
M
M
M
M
M
Is case suspected to be due to healthcare associated transmission?
Is patient alive?
Yes
No
Unknown
M
M
M
Is patient pregnant?
Yes
No
Unknown
M
M
M
_______ /_______ /______
_______ /_______ /_______
If no, date of death:
Yes
No
Unknown
If yes, due date:
M
M
M
Was patient admitted to hospital?
Yes
No
Unknown
Is patient a newborn infant?
Yes
No
Unknown
M
M
M
M
M
M
_______ /_______ /_______
Admission date:
If yes, name of hospital where infant was born
_______ /_______ /_______
Discharge date:
Name of facility where infant’s mother obtained prenatal care
Foreign travel
_______ /_______ /_______
Countries
Date returned to U.S.
Other Information
Name of Person Reporting Disease
Email address
Phone
Name of Facility of Person Reporting Disease
National Provider Identifier (NPI) Code
Permanent Facility Identifier (PFI) Code
Facility Street Address
State
Zip Code
City
Name of Hospital/Healthcare Facility Providing Care for Patient
Permanent Facility Identifier (PFI) Code
Facility National Provider Identifier (NPI) Code
Facility Street Address
City
State
Zip Code
Name of Testing Laboratory
Phone
CLIA Number
Laboratory Street Address
State
Zip Code
City
Name of Provider Caring for Patient
National Provider Identifier (NPI) Code
Fax
Email address
Phone
Mobile
Provider Street Address
City
State
Zip Code
-1-
Form PD-16 (Rev. 3/2017)
New York City Department of Health and Mental Hygiene
Universal Reporting Form
To report an immediately notifiable disease or condition, an outbreak among three or more persons or an unusual manifestation of any disease or
condition, or any newly apparent or emerging disease or syndrome, call the Provider Access Line at 866-692-3641.
Diseases and conditions in green and marked with * are immediately notifable; those marked with † are immediately notifiable if case meets the risk
group criteria on page 2. Report by calling 866-692-3641.
For all other diseases and conditions, report using Reporting Central online via NYCMED at www.nyc.gov/health/nycmed, mail this form to the NYC
Department of Health and Mental Hygiene, 42-09 28 th Street, CN-22, Long Island City, NY 11101, or call 866-692-3641 for the appropriate fax number.
Go to www.nyc.gov/health/diseasereporting for more information.
Patient Information
Patient Last Name
First Name
Middle Name
DATE OF REPORT
Patient AKA: Last Name
AKA: First Name
AKA: Middle Name
_______ /_______ /_______
Age
Date of Birth
Country of Birth
Social Security Number
DATE OF DIAGNOSIS
_______ /_______ /_______
If patient is a child, Guardian Last Name
Guardian First Name
Guardian Middle Name
_______ /_______ /_______
Medicaid Number
Medical Record Number
DATE OF ILLNESS ONSET
Patient Home Address
City
State
Zip Code
_______ /_______ /_______
Country
Borough:
Manhattan
Bronx
Brooklyn
Queens
Staten Island
Unknown
Not NYC
M
M
M
M
M
M
M
Email Address
Mobile Phone
Home Phone
Homeless
M
Sex
Male
Transgender MTF
Race
Black
American Indian/Alaska Native
Asian
Ethnicity
Hispanic
M
M
M
M
M
M
r
Unknown
Female
Transgender FTM
Unknown
White
Native Hawaiian/Pacific Islande
Other: _____________________
Unknown
Non-Hispanic
M
M
M
M
M
M
M
M
M
Is case suspected to be due to healthcare associated transmission?
Is patient alive?
Yes
No
Unknown
M
M
M
Is patient pregnant?
Yes
No
Unknown
M
M
M
_______ /_______ /______
_______ /_______ /_______
If no, date of death:
Yes
No
Unknown
If yes, due date:
M
M
M
Was patient admitted to hospital?
Yes
No
Unknown
Is patient a newborn infant?
Yes
No
Unknown
M
M
M
M
M
M
_______ /_______ /_______
Admission date:
If yes, name of hospital where infant was born
_______ /_______ /_______
Discharge date:
Name of facility where infant’s mother obtained prenatal care
Foreign travel
_______ /_______ /_______
Countries
Date returned to U.S.
Other Information
Name of Person Reporting Disease
Email address
Phone
Name of Facility of Person Reporting Disease
National Provider Identifier (NPI) Code
Permanent Facility Identifier (PFI) Code
Facility Street Address
State
Zip Code
City
Name of Hospital/Healthcare Facility Providing Care for Patient
Permanent Facility Identifier (PFI) Code
Facility National Provider Identifier (NPI) Code
Facility Street Address
City
State
Zip Code
Name of Testing Laboratory
Phone
CLIA Number
Laboratory Street Address
State
Zip Code
City
Name of Provider Caring for Patient
National Provider Identifier (NPI) Code
Fax
Email address
Phone
Mobile
Provider Street Address
City
State
Zip Code
-1-
Form PD-16 (Rev. 3/2017)
Patient Last Name
First Name
Medical Record Number
Diseases and conditions in green and marked with * are immediately notifable; those marked with † are immediately notifiable if case meets the
risk group criteria at the bottom of the page. Report by calling 866-692-3641.
For all other diseases and conditions, report using Reporting Central online via NYCMED at www.nyc.gov/health/nycmed,
mail this form to the NYC Department of Health and Mental Hygiene, 42-09 28 th Street, CN-22, Long Island City, NY 11101,
or call 866-692-3641 for the appropriate fax number.
Go to www.nyc.gov/health/diseasereporting for more information.
*
Ricin poisoning
M
influenza
amebiasis
Haemophilus influenzae (invasive disease)
M
M
Rickettsialpox
M
Suspected novel viral strain with pandemic
M
anaplasmosis (Human granulocytic anaplasmosis)
Test type:
M
Rocky Mountain spotted fever
V Culture
V Antigen
M
*
potential (e.g., avian H5N1 or H7N9)
animal bite
– see Environmental Conditions
*
V PCR
Rubella (German measles)
V Gram stain
M
M
Death in a child aged 18 or younger
section on page 3. See rabies if potential for
V Other ____________________
Rubella syndrome, congenital
exposure.
M
lead poisoning
– see Poisonings section on page 3
*
Specimen Source:
Salmonellosis
anthrax
M
M
legionellosis
M
Serogroup: ______________________
V Blood
V CSF
V Unknown
*
arboviral infections, acute
M
Specify positive test:
If due to Salmonella typhi or paratyphi,
V Other ______________________
Specify which virus: ______________________
V Culture
V Urine antigen
select Typhoid or Paratyphoid Fever.
If Chikungunya, Dengue, West Nile, Yellow Fever or
Specify Serotype:
V DFA
V Serology
Severe or novel coronavirus (e.g., SARS or
M
Zika report as such.
V Type B
V Not typeable
*
MERS-CoV)
V NAAT or PCR
Attach copies of diagnostic laboratory results if
V Not tested
V Unknown
available.
leprosy (Hansen’s disease)
M
Shiga-toxin producing Escherichia coli (STEC)
M
V Other ______________________
infection
babesiosis
M
leptospirosis
M
*
Shigellosis
M
Hantavirus disease
*
M
M
listeriosis
botulism
M
*
Smallpox (variola)
M
Foodborne
Infant
Wound
lyme disease
M
V
V
V
Hemolytic uremic syndrome
M
*
Staphylococcal enterotoxin b poisoning
*
M
brucellosis
Erythema migrans present?
M
FOR All HepAtitis RepORts
M
Staphylococcus aureus, vancomycin
V Yes
V No
V Unknown
Campylobacteriosis
M
intermediate (VISA) and resistant (VRSA)*
lymphocytic choriomeningitis virus
M
*
Jaundice
V Yes
V No
V Unknown
Carbon Monoxide poisoning
– see Poisonings
Source: _________
lymphogranuloma venereum
section on page 3
– see STD section
ALT (SGPT) value:___________
V Unknown
MIC (µg/ml): ______
on page 4
Chancroid
– see STD section on page 4
Lab reference range:_________
V Unknown
Streptococcus (Group A and B) invasive
Malaria
M
M
Chikungunya
M
Specify Source: V Blood V CSF V Unknown
Select at least one of the following:
Hepatitis a
Chlamydia
M
– see STD section on page 4
V Other, Specify:___________
Total Ab to Hepatitis A is NOT reportable.
V falciparum
V vivax
V malariae
*
Cholera
M
Syphilis, including congenital
– see STD section
IgM anti-HAV:
V Pos
V Neg V Unknown
V ovale
V undetermined
on page 4
Creutzfeldt-Jakob disease
– see Transmissable
Hepatitis b
M
Complete Foreign Travel section on page 1.
spongiform encephalopathy
tetanus
M
Report at least one positive hepatitis B test result.
*
Measles (rubeola)
M
toxic shock syndrome
Cryptosporidiosis
M
M
Total Ab to Hepatitis B is not reportable.
*
Melioidosis
M
trachoma
IgM anti-HBc:
V Pos
V Neg V Unknown
M
Cyclosporiasis
M
Meningitis, bacterial
M
HBsAg:
V Pos
V Neg V Unknown
transmissible spongiform encephalopathy
M
Dengue
M
Specify bacteria identified _________________
(Creutzfeldt-Jakob disease and variants)
Attach copies of dengue diagnostic laboratory
HBeAg:
V Pos
V Neg V Unknown
Meningococcal disease, invasive (including
M
Testing done: _________________
results if available.
HBV Nucleic Acid: V Pos
V Neg V Unknown
*
(e.g. 14-3-3 on CSF, brain biopsy, autopsy, EEG/MRI)
meningitis)
*
Diphtheria
M
If IgM is positive, describe symptoms and risk in
trichinosis
M
Test type/Specimen source:
Drownings
– see Environmental Conditions
comments box on last page.
tuberculosis
– see Tuberculosis section on page 3
V Blood culture
V CSF culture
section on page 3
Hepatitis b in pregnancy
*
tularemia
V Antigen test from CSF
V Gram stain
M
ehrlichiosis (Human monocytic ehrlichiosis)
M
Report cases in Reporting Central or fax IMM-5 form
V Other ____________________
V PCR
typhoid fever
If human granulocytic anaplasmosis report as
M
to 347-396-2558. For more information, call
anaplasmosis.
347-396-2403.
*
Monkeypox
vaccinia disease (adverse events associated
M
M
encephalitis
Hepatitis C
*
M
M
Mumps
with smallpox vaccination)
M
If
Jul.1–Oct. 31 consider and test for West Nile virus.
Check all that apply:
paratyphoid fever
M
Vibrio species, non-cholera
M
If due to another reportable disease (e.g. Lyme, West
V EIA pos
Specify species:________________________
pertussis (whooping cough)
M
Nile, arbovirus), report under the other disease.
V HCV Nucleic Acid (e.g.PCR) pos
*
pesticide poisoning
viral hemorrhagic fever
M
- see Poisonings section on
M
Escherichia coli O157:H7 infection
M
Is this an acute infection?
page 3
West Nile fever and viral neuroinvasive disease
M
Falls from windows
– see Environmental
V Yes
(e.g., meningitis and encephalitis)
*
plague
M
Conditions section on page 3
Attach copies of diagnostic laboratory results
V No
poisoning
– see Poisonings section on page 3
if available.
Food poisoning in a group of 2 or more
M
V Unknown
*
*
poliomyelitis
individuals
M
*
yellow fever
M
Herpes, neonatal
– see STD section on page 4
psittacosis
M
Attach copies of diagnostic laboratory results if
Giardiasis
M
available.
*
Q Fever
Hiv/aiDS
M
*
Glanders
M
yersiniosis, non-plague
M
*
Report using the New York State Provider Report
Rabies and exposure to rabies
M
– see animal
Gonorrhea
– see STD section on page 4
Zika
Form (PRF). Call 518-474-4284 for forms or
M
bites in Environmental Conditions section on page 3
Granuloma inguinale
– see STD section on page 4
212-442-3388 for more information.
*Report suspected and confirmed cases immediately to 1-866-692-3641
if case meets any of the risk group criteria below, report immediately to 1-866-692-3641
Risk Groups for Disease Exposure/Transmission
Complete this section for diseases marked with † and if case meets any criteria, report it immediately to 1-866-692-3641.
patient works in:
Childcare
Health care facility
Long-term care facility/Nursing home
Clinical/Research laboratory
M
M
M
M
Unknown
Food service
Correctional facility
Position with routine animal contact
Other
M
M
M
M
M
patient attends/resides in:
Assisted living facility
School
Dormitory
Long-term care facility/nursing home
M
M
M
M
Unknown
Correctional facility
Shelter
Day care/group baby-sit
Other congregate living facility (specify: _________________________ )
M
M
M
M
M
-2-
Patient Last Name
First Name
Medical Record Number
Environmental Conditions
animal bites
M
Drownings
M
*
exposure to rabies
M
Respiratory impairment from submersion/immersion
Including a bite or other exposure to any animal confirmed to have rabies, or from any rabies vector species (raccoon, bat, skunk, fox or coyote),
in liquid.
or any mammal exhibiting signs suggestive of rabies.
Drowning Location: ___________________________
Outcome:
j
Death
j
Morbidity
j
No Morbidity
_______ /_______ /_______
Animal Species:
Date of Bite:
Area of body bitten:
Breed:
Color(s):
Activity at time of bite: ________________________________________
j
Owned
j
Stray
j
Unknown
Place of occurrence:__________________________________________
Window Falls
M
Owner’s Name:
Treatment given: ____________________________________________
Falls from windows of buildings with 3 or more dwellings,
by children aged 16 years and younger, report by calling
Address:
Rabies prophylaxis
j
Yes
j
No
646-632-6204 or on Child Window Fall Notification Report
City, State, Zip:
HRIG
j
Yes
j
No
paper form.
Phone:
Rabies Vaccine
j
Yes
j
No
Poisonings
QUANTITY
SYMPTOM ASSESSMENT
(Check all that apply)
ROUTE OF ExPOSURE
CHEMICAL
REASON AND SETTING
Intentional:
Unintentional:
Suspected suicide
j Milliliter (mL) _______
lead
j
Ingestion
M
j
None
Seizure
j
j
General
Misuse
j
j
j Mouthful
_______
For persons aged 16 and older indicate:
Ocular
j
Electrolyte abnormalities
Nausea/vomiting/diarrhea
j
j
Environmental
Abuse
j
j
Employer_____________________
j Sip
_______
Dermal
Cough/shortness of
Lethargic/stupor/coma
j
Indoor
Outdoor
Unknown
j
j
j
j
j
Employer phone________________
j Tablespoon
_______
Misuse
Agitated
breath
Inhalation
j
j
j
Other:
*
Carbon Monoxide
j Tab/pill/cap
_______
M
Bite/sting
j
Hypertensive
Occular irritation
Aural
j
j
Contamination/
j
j
j Taste/lick/drop _______
Food poisoning
Source:
Furnace/Boiler
Generator
j
j
j
Hypotensive
Skin irritation
tampering
j
j
Bite
j
Occupational
j
j Teaspoon
_______
Other _________________
Vehicle
j
j
Malicious
Tachycardia
Unknown
j
j
j
Dietary
Sting
j
j
j Unknown
arsenic
Cadmium
Withdrawal
M
M
j
Brachycardia
Other
j
Consumer product
j
j
IV
j
Mercury
pesticide
M
M
__________________
Pesticide
Adverse reaction:
j
DATE AND TIME OF ExPOSURE
other_____________________________
Medication
M
j
Drug
______
______
______
j
/
/
(accidental ingestion)
Food
j
PROVIDER TREATMENT
____ ____ : ____ ____
Unknown
j
Other
j
No therapy required
Irrigated eye
AM
PM
j
j
j
j
Unknown
SPECIMEN SOURCE
Laboratory Accession Number
j
Oral fluids
Oxygen
j
j
_____________________
Capillary
Venous
Urine
j
j
j
Emesis
Naxolone
j
j
Results (units) ___________
Other _____________
VITAL SIGNS
j
Lavage
50% Dextrose/Thiamine
_______
j
j
Resp:
Pupils:
_________
Body Weight
Date Collected
Activated charcoal
Alkalinize urine
Purpose of test:
j
j
_______
Pounds
Kilograms
_______ /_______ /_______
Dilated
j
j
Temp:
F
C
j
j
j
Cathartic
N-acetylcysteine
j
j
Initial
Repeat
j
j
(Mucromyst)
_______
Chelation
Constricted
Pulse:
j
j
Follow-up
Date Analyzed
j
: __ __ __/ __ __ __
Other _____________
BP
j
Insect sting mgmt.
j
_______ /_______ /_______
Tuberculosis
___ /___/___
Patient status at time of reporting:
AFB Smear:
Test for TB Infection:
CT Scan
j
/ MRI
j
< 5 years old with LTBI
Positive
j
j
History of positive test result
Body Site:
j
j
TB suspect or case
Smear Grade:
suspicious
Chest
Neck
j
j
j
Year (yyyy): _______
1+ rare
2+ few
j
Abdomen
j
Pelvis
j
j
____ /____ /______
Date of most recent test:
3+ moderate
4+ numerous
Spine
j
j
Head
j
j
Indicate all sites of disease for TB suspect or case:
Other: _______________
Negative
Pending
j
j
j
j
Unknown
Type of Test:
Pulmonary
j
Not Done
Unknown
j
j
Tuberculin Skin Test (TST/PPD)
Lymphatic
j
j
Normal
j
Nucleic Acid Amplification (NAA):
Bone/Joint
QuantiFERON
TB-Gold in tube (QFT-GIT)
j
®
Abnormal
j
Test type:
j
Soft tissue/Muscles
j
T-Spot.TB
j
j
Positive
j
Negative
Consistent with TB
j
Peritoneal
j
Pending
Not Done
Other: _____________
j
j
j
Evidence of Cavity
j
j
Meningeal
Unknown
j
Evidence of Miliary TB
Genitourinary
j
j
Result:
Mutation analysis test type: __________________
Not consistent with TB
j
Gastrointestinal
Mutation detected?
j
Positive
Negative
Unknown
j
j
j
Other: _______________
j
j
Yes
j
No
j
Unknown
Indeterminate
Borderline
j
j
If yes, list the genes with mutations:_____________
Induration _____________ mm
___ /____/____
Collection date:
j
Unknown
M. tb Complex Culture:
Positive
Negative
j
j
Treatment:
On Anti-TB Medications
Yes
No
Unknown
j
j
j
Laboratory Results:
Pending
Contaminated
j
j
Please complete for each medication: Dose (mg) Frequency/day Start Date
Specimen Number:
______________
Not Done
Unknown
j
j
Medication
Dose (mg)
Frequency/day
Start Date
j
Unknown
Pathology consistent with TB:
Isoniazid (INH)
/
/
Yes
Unknown
j
j
No
j
Not Done
j
Specimen Source:
_______ /_______ /_______
Date:
Rifampin (RIF)
/
/
Sputum
j
Pathology Specimen Number:
Pyrazinamide (PZA)
/
/
j
Tracheal aspirate
s
s
Pathology
pecimen
ource _________________
Ethambutol (EMB)
/
/
Bronchial fluid/Broncho-alveolar lavage
j
Pathology Findings:
j
Lymph node
Other 1
/
/
Lung tissue
j
Other 2
/
/
_______ /_______ /_______
Pleural fluid
Chest x-Ray:
j
Other 3
/
/
Pleura
j
j
Normal
Blood
Abnormal
j
j
Consistent with TB
Urine
Airborne Isolation:
j Yes
j No
j Unknown
j
j
Evidence of Cavity
Other: _____________________________
j
j
If yes, date initiated: _____ /_____ /_____ Date discontinued: _____ /_____ /_____
Evidence of Miliary TB
j
Describe other medical problems or other pertinent information in the comments box on the last page.
Not consistent with TB
j
* Report suspected and confirmed cases immediately to 1-866-692-3641
if case meets any of the risk group criteria on page 2, report immediately to 1-866-692-3641.
-3-
Patient Last Name
First Name
Medical Record Number
Sexually Transmitted Diseases
For All STD Reports
as of the date of this report,
Were any of this patient’s sex partners notified
Did you provide treatment for any of this
is the patient on pre-exposure prophylaxis
please indicate gender of sexual partners
patient’s partners?
in the past year:
of possible exposure to an StD?
(prep) to prevent Hiv infection?
(Check all that apply)
(Check all that apply)
(Check all that apply)
j
Yes, i saw the sex partner(s) in my office
j
Yes, started prep at time of current stD
j
Males
j
Yes, our office notified the partner(s)
diagnosis
j
Yes, i gave extra medication for ___(#) partner(s)
j
Females
j
Yes, already on prep at time of current stD
j
Yes, the patient was asked to notify partner(s)
Yes, i wrote a prescription for ___(#) partner(s)
j
transgender Male to Female
j
diagnosis
j
Yes, some other way (specify):_______
j
No
transgender Female to Male
j
j
No
j
No
j
Unknown
j
Unknown
j
Unknown
j
Unknown
Syphilis Test Types: (Check all that apply)
M
M
M
lymphogranuloma venereum
Chancroid
Granuloma inguinale
Clinical Presentation (Check all that apply)
Specify type of specimen:
Specify type of specimen:
1. Serologic tests for syphilis
j
j
Lymphadenopathy
Proctitis
j
j
j
Penile
Vaginal
Endocervical
j
j
j
Penile
Vaginal
Endocervical
A. Non-treponemal Test
j
j
Anorectal
Oropharyngeal
j
Skin lesion
j
j
j
Anorectal
Oropharyngeal
Buboe
j
RPR
j Reactive j Non-reactive
j
Other:
j
j
Other
Other:
Titer
_____ /____ /_____
____ /____ /_____
Specimen collection date:
____ /____ /_____
Specimen collection date:
Specimen collection date:
Treatment:
j
Treatment:
_
Treatment:
VDRL
j Reactive j Non-reactive
____/____ /____
____ /____ /____
____ /____ /____
Treatment date:
j Unknown
Treatment date:
j Unknown
Treatment date:
j Unknown
Titer
M
M
M
Chlamydia (CT)
Herpes, neonatal
Syphilis**
____ /____ /_____
Specimen collection date:
Stage:
Herpes simplex virus infection in infants aged 60
Specify type of specimen:
days and younger.
j
Congenital
j Endocervical
j Urethral
j Anorectal
B. Treponemal Test
j
j Clinical diagnosis
Primary, chancre present (Check all that apply)
j Oropharyngeal j Urine
j
j
j
Penile
Vaginal
Endocervical
j
j
j
TP-PA/MHA-TP
Reactive
Non-reactive
j Lab confirmed diagnosis
j Other:
j
j
Anorectal
Oropharyngeal
j Culture
j PCR
j
FTA
j
Reactive
j
Non-reactive
Specify test type:
j
Other:
j Other
j Culture
j Nucleic acid amplification
j
j
j
Treponemal IgG
Reactive
Non-reactive
j
(Check all that apply)
Secondary
j Nucleic acid hybridization
Herpes type: j Type 1
j Type 2
j Not typed
j EIA
j DFA
j
j
Alopecia
Condylomata
____ /____ /_____
Clinical Syndrome (Check all that apply)
Specimen collection date:
j Other:
j
j
Mucous patches
Rash
j Skin, eye, mucous membrane infection
____ /____ /_____
Specimen collection date:
j
Early Latent
2. Cerebrospinal fluid tests
j CNS involvement
Treatment:
no symptoms, infection ≤ 1 year duration
j Disseminated disease
j CSF VDRL
j Reactive j Non-reactive
___ /____ /___
j
Late Latent
Treatment date:
j Unknown
j Reactive j Non-reactive
j CSF FTA
Herpes lesions present?
no symptoms, infection of > 1 year duration
Result
j Other Test:
j Yes, anatomic site____________________
M
Gonorrhea* (GC)
j
Tertiary, gumma or cardiovascular
j No
Specify type of specimen:
Neurologic symptoms present?
____ /____ /_____
Specimen collection date:
j Unknown
j Endocervical
j Urethral
j Anorectal
j
j
j
Yes
No
Unknown
____ /____ / ___
j Oropharyngeal
j Urine
Specimen collection date:
j Yes
j No
Ocular symptoms present?
j Elevated CSF protein
Treatment for infant:_____________________
j Other:
j
Unknown
j
j
Yes
No
j Yes
j No
j Elevated CSF leukocytes
Specify test type:
Otic symptoms present?
____ /____ /___
Treatment date:
j Unknown
j Culture
j Nucleic acid amplification
____ /____ /___
j
j
j
Yes
No
Unknown
Specimen collection date:
Mother’s Name:
j Nucleic acid hybridization
Treatment – list medication and dosage below:
j Other:
____ /____ /_____
Mother’s DOB:
3. Organism visualization
Birth Hospital
____ /____ /_____
Specimen collection date:
j Darkfield
j Positive j Negative
Mother’s Labor and Delivery Medical Record No:
Treatment 1
*
:
mg/gram
j Other Test:
Result
*
Treatment 2
:
mg/gram
___ /____ /___
Treatment date:
j Unknown
____ /____ /_____
Specimen collection date:
Continue to next column
____ /____ /____
Treatment date:
j Unknown
* For uncomplicated gonococcal infections of the cervix, urethra, anorectum or pharynx, CDC recommends dual therapy (irrespective of concurrent chlamydial infection) using
BOTH Ceftriaxone 250mg IM AND Azithromycin 1g PO.
** Licensed health care providers can access current and historical syphilis test results and treatment information in the New York City Syphilis Registry to inform the diagnosis and management of syphilis in their
patients. For more information, see the Syphilis Registry check at: http://www1.nyc.gov/assets/doh/downloads/pdf/std/hcp-syphilis-registry-check.pdf, or call 347-396-7201
Comments:
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