"New Hampshire Lyme Disease Case Report Form - Health Care Provider" - New Hampshire

New Hampshire Lyme Disease Case Report Form - Health Care Provider is a legal document that was released by the New Hampshire Department of Health and Human Services - a government authority operating within New Hampshire.

Form Details:

  • Released on March 1, 2014;
  • The latest edition currently provided by the New Hampshire Department of Health and Human Services;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Health and Human Services.

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NEW HAMPSHIRE LYME DISEASE CASE REPORT FORM
HEALTH CARE PROVIDER
Patient’s Name______________________________________________________________Report Date ________________
(Last Name)
(First Name)
Race
White
Date of Birth__________________ Age_____________
Male
Female
Unknown
African American
Asian
Address_____________________________________________________________________
Hawaiian or Pacific Islander
Native Am./Alaskan Native
Other
City / Town_____________________County________________ State______ Zip_________
Unknown
Ethnicity
Home Phone_____________________________Work Phone__________________________
Hispanic
Not Hispanic
Occupation:_________________________________________________________________
Unknown
SYMPTOMS AND SIGNS OF CURRENT EPISODE
(Please answer each question)
Is this person being diagnosed with Lyme Disease?……………… ……………………………………
Yes
No
Date of symptom onset______________
Onset date unknown
Date of Lyme Disease diagnosis_________________
DERMATOLOGIC:
Erythema migrans (physician diagnosed EM at least 5 cm in diameter)?…………………
Yes
No
Unknown
RHEUMATOLOGIC:
Arthritis characterized by recurrent brief attacks of joint swelling? ………………………
Yes
No
Unknown
NEUROLOGIC:
Bell’s palsy or other cranial neuritis? ………………………………………………………
Yes
No
Unknown
Radiculoneuropathy? ……………………………………………………………….………
Yes
No
Unknown
Lymphocytic meningitis? ……………………………….………………….………………
Yes
No
Unknown
Encephalitis/Encephalomyelitis? ……………………….………………………………….
Yes
No
Unknown
CSF tested for antibodies to B. burgdorferi? …………….…………………………………
Yes
No
Unknown
Antibody to B. burgdorferi higher in CSF than serum ………………………..……………
Yes
No
Unknown
CARDIOLOGIC:
nd
rd
Acute onset 2
or 3
degree atrioventricular block? ………………………………………
Yes
No
Unknown
Pregnant:
Yes
No
Unknown
Hospitalized:
Yes
No
Unknown If yes, where______________________________________________________
Treatment:
Doxycycline
Amoxicillin
Other: _________________________
Duration of treatment in days: __________________
Has this patient been diagnosed with Lyme Disease prior to this diagnosis?
Yes, date
_________
No
Unknown
(mm/yyyy)
EXPOSURE HISTORY
Tick Bite reported within 30 days of onset:
Yes
No
Unknown
In the 30 days prior to symptom onset, did this individual travel outside of NH:
Yes, out of state
Yes, out of country
No
Unknown
County and state most likely exposed?_____________________________
LABORATORY RESULTS
(Check all that apply)
EIA/IFA:
Positive
Equivocal
Negative
Not done/Unknown
Date if positive:________________________
Western Blot:
IgM Positive
IgM Negative
Not done/Unknown
Date if positive:_______________________
IgG Positive
IgG Negative
Not done/Unknown
Date if positive:________________________
Culture Results/Other:__________________________________________________________________________________________
For NH DHHS Staff Only
HEALTH CARE PROVIDER REPORTING INFORMATION:
Imported
Reported by _________________________________________________________________
Acquired in NH
Acquired Outside US
Ordering Provider ____________________________________Phone ___________________
Acquired in Another State
Unknown
Provider Facility______________________________________________________________
Case Status
City/Town _________________________________State ____________ Zip______________
Confirmed (meets CDC definitions)
Probable (meets CDC definitions)
Suspected (meets CDC definitions)
Not A Case
Mail or Fax to: NH Department of Health and Human Services,
Out of state
Bureau of Infectious Disease Control
Notes:
29 Hazen Drive, Concord, NH 03301. Fax: (603) 271-0545,
Phone: Hotline 1 (888) 836-4971.
vMar14
NEW HAMPSHIRE LYME DISEASE CASE REPORT FORM
HEALTH CARE PROVIDER
Patient’s Name______________________________________________________________Report Date ________________
(Last Name)
(First Name)
Race
White
Date of Birth__________________ Age_____________
Male
Female
Unknown
African American
Asian
Address_____________________________________________________________________
Hawaiian or Pacific Islander
Native Am./Alaskan Native
Other
City / Town_____________________County________________ State______ Zip_________
Unknown
Ethnicity
Home Phone_____________________________Work Phone__________________________
Hispanic
Not Hispanic
Occupation:_________________________________________________________________
Unknown
SYMPTOMS AND SIGNS OF CURRENT EPISODE
(Please answer each question)
Is this person being diagnosed with Lyme Disease?……………… ……………………………………
Yes
No
Date of symptom onset______________
Onset date unknown
Date of Lyme Disease diagnosis_________________
DERMATOLOGIC:
Erythema migrans (physician diagnosed EM at least 5 cm in diameter)?…………………
Yes
No
Unknown
RHEUMATOLOGIC:
Arthritis characterized by recurrent brief attacks of joint swelling? ………………………
Yes
No
Unknown
NEUROLOGIC:
Bell’s palsy or other cranial neuritis? ………………………………………………………
Yes
No
Unknown
Radiculoneuropathy? ……………………………………………………………….………
Yes
No
Unknown
Lymphocytic meningitis? ……………………………….………………….………………
Yes
No
Unknown
Encephalitis/Encephalomyelitis? ……………………….………………………………….
Yes
No
Unknown
CSF tested for antibodies to B. burgdorferi? …………….…………………………………
Yes
No
Unknown
Antibody to B. burgdorferi higher in CSF than serum ………………………..……………
Yes
No
Unknown
CARDIOLOGIC:
nd
rd
Acute onset 2
or 3
degree atrioventricular block? ………………………………………
Yes
No
Unknown
Pregnant:
Yes
No
Unknown
Hospitalized:
Yes
No
Unknown If yes, where______________________________________________________
Treatment:
Doxycycline
Amoxicillin
Other: _________________________
Duration of treatment in days: __________________
Has this patient been diagnosed with Lyme Disease prior to this diagnosis?
Yes, date
_________
No
Unknown
(mm/yyyy)
EXPOSURE HISTORY
Tick Bite reported within 30 days of onset:
Yes
No
Unknown
In the 30 days prior to symptom onset, did this individual travel outside of NH:
Yes, out of state
Yes, out of country
No
Unknown
County and state most likely exposed?_____________________________
LABORATORY RESULTS
(Check all that apply)
EIA/IFA:
Positive
Equivocal
Negative
Not done/Unknown
Date if positive:________________________
Western Blot:
IgM Positive
IgM Negative
Not done/Unknown
Date if positive:_______________________
IgG Positive
IgG Negative
Not done/Unknown
Date if positive:________________________
Culture Results/Other:__________________________________________________________________________________________
For NH DHHS Staff Only
HEALTH CARE PROVIDER REPORTING INFORMATION:
Imported
Reported by _________________________________________________________________
Acquired in NH
Acquired Outside US
Ordering Provider ____________________________________Phone ___________________
Acquired in Another State
Unknown
Provider Facility______________________________________________________________
Case Status
City/Town _________________________________State ____________ Zip______________
Confirmed (meets CDC definitions)
Probable (meets CDC definitions)
Suspected (meets CDC definitions)
Not A Case
Mail or Fax to: NH Department of Health and Human Services,
Out of state
Bureau of Infectious Disease Control
Notes:
29 Hazen Drive, Concord, NH 03301. Fax: (603) 271-0545,
Phone: Hotline 1 (888) 836-4971.
vMar14