"Borrelia Miyamotoi Case Report Form" - Connecticut

Borrelia Miyamotoi Case Report Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on February 19, 2019;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Public Health.

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Download "Borrelia Miyamotoi Case Report Form" - Connecticut

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Connecticut Department of Public Health
Borrelia miyamotoi Case Report Form
Demographic Information
Last Name:
First Name:
MI:
Phone Number:
Street Address:
City:
State:
Zip Code:
Sex:  Male
 Female
 Unknown
Date of Birth:
Age:
 White
 Black/African American
 Asian
 American Indian/Alaskan Native
Race:
 Native Hawaiian/Pacific Islander
 Other
 Unknown
Ethnicity:  Hispanic/Latino
 Not Hispanic/Latino
Pregnant:  Yes
 No
 Unknown
Occupation:
Reporting Information
Reporter:
Phone Number:
Report Date:
Provider and Hospitalization Information
 Yes
 No
 Unknown
Date first seen by provider:
Hospitalized:
Provider Name:
Hospital:
Provider Phone Number:
Admission Date:
Discharge Date:
Outcome:  Recovered, no complications
 Recovered, complications (specify)______________________________
 Recovered, no information about complications
 Died (date of death)
Unknown
Diagnostic Laboratory Information
Lab Test
Collection Date
Result
Specimen Type
Laboratory
B. miyamotoi culture
Select one
B. miyamotoi PCR
Select one
IgG by Indirect ELISA
Select one
B. Miyamotoi IgM and
Select one
IgG detection
Blood smear
Other:
List concurrent testing for other tick-borne diseases below.
Lab Test
Collection Date
Result
Specimen Type
Laboratory
1
V1. 02/19/2019
Connecticut Department of Public Health
Borrelia miyamotoi Case Report Form
Demographic Information
Last Name:
First Name:
MI:
Phone Number:
Street Address:
City:
State:
Zip Code:
Sex:  Male
 Female
 Unknown
Date of Birth:
Age:
 White
 Black/African American
 Asian
 American Indian/Alaskan Native
Race:
 Native Hawaiian/Pacific Islander
 Other
 Unknown
Ethnicity:  Hispanic/Latino
 Not Hispanic/Latino
Pregnant:  Yes
 No
 Unknown
Occupation:
Reporting Information
Reporter:
Phone Number:
Report Date:
Provider and Hospitalization Information
 Yes
 No
 Unknown
Date first seen by provider:
Hospitalized:
Provider Name:
Hospital:
Provider Phone Number:
Admission Date:
Discharge Date:
Outcome:  Recovered, no complications
 Recovered, complications (specify)______________________________
 Recovered, no information about complications
 Died (date of death)
Unknown
Diagnostic Laboratory Information
Lab Test
Collection Date
Result
Specimen Type
Laboratory
B. miyamotoi culture
Select one
B. miyamotoi PCR
Select one
IgG by Indirect ELISA
Select one
B. Miyamotoi IgM and
Select one
IgG detection
Blood smear
Other:
List concurrent testing for other tick-borne diseases below.
Lab Test
Collection Date
Result
Specimen Type
Laboratory
1
V1. 02/19/2019
Connecticut Department of Public Health
Borrelia miyamotoi Case Report Form
Clinical Information
Onset Date:
Final provider diagnoses:
Symptoms
 Yes
 No
 Unknown
 Yes
 No
 Unknown
Fever:
Malaise/fatigue
 Yes
 No
 Unknown
If yes, highest temperature (˚F):
Dyspnea:
 Yes
 No
 Unknown
 Yes
 No
 Unknown
If yes, relapsing?
Anorexia:
 Yes
 No
 Unknown
 Yes
 No
 Unknown
Headache:
Abdominal pain:
 Yes
 No
 Unknown
 Yes
 No
 Unknown
Chills:
Nausea:
 Yes
 No
 Unknown
 Yes
 No
 Unknown
Myalgia:
Diarrhea:
 Yes
 No
 Unknown
 Yes
 No
 Unknown
Arthralgia:
Dizziness:
 Yes
 No
 Unknown
 Yes
 No
 Unknown
Rash:
Meningitis/Encephalitis:
 Yes
 No
 Unknown
Vomiting:
 erythematous  maculopapular
If yes, type of rash:
 erythema migrans  petechial  other:
 Yes
 No
 Unknown
Photophobia:
 Yes
 No
 Unknown
 Yes
 No
 Unknown
Other skin manifestations
Lymphadenopathy:
 localized
 generalized
If yes, describe:
If yes:
  other:
Other Symptoms:
 Yes
 No
 Unknown
Does patient have underlying medical conditions or is patient immunocompromised?
If yes, check all that apply:  cancer
 immunosuppressive medications
 diabetes
 other underlying condition/immunodeficiency; specify:
Clinical Laboratory Information
 Yes
 No
 Unknown
 Yes
 No
 Unknown
Thrombocytopenia:
Leukopenia:
 Yes
 No
 Unknown
 Yes
 No
 Unknown
Neutropenia:
Elevated Liver Enzymes:
Exposure Information
In the 30 days before illness onset did the patient:
Date(s):
 Yes
 No
 Unknown
Have exposure to ticks or tick habitat?
 Yes
 No
 Unknown
Have a tick bite?
 Yes
 No
 Unknown
Receive a blood transfusion or organ transplant?
 Yes
 No
 Unknown
Donate blood or organ?
 Yes
 No
 Unknown
Travel out of state?
If yes, location of travel:
Other notes about exposure:
2
V1. 02/19/2019
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