Pandemic Influenza Plan - Questar III

NYSDOH Novel Influenza Case Report Form
State case ID: ___________________ Appendix 2-B
6. Did the patient receive antiviral medication?
If YES,
Antiviral Name: ______________________ Dosage: ______________ Route: _______________
Date started: _______/ _______/ ________ Date ended: _______/ _______/ ________
Yes
No Unknown
Existing Medical Conditions and Medication History
1. Did the patient have any underlying medical conditions? Yes No Unknown
2. IF YES, please check all that apply:
Asthma/reactive airway disease
Other chronic lung disease (specify) _______________________
Cardiac disease (specify) _________________________ Immunosuppressive condition (specify) ____________________
Cystic fibrosis
Pregnant (specify gestational age in weeks) _________________
Developmental delay (moderate to severe)
History of febrile seizures before current illness
Diabetes mellitus (Insulin dependent)
Seizure disorder requiring anti-seizure medications
Hemoglobinopathy (e.g. sickle cell disease, not trait) Renal disease (specify): _________________________________
Metabolic disorder (specify) _______________________ Neuromuscular disorder (including cerebral palsy) (specify)
Other (specify) __________________________________ _______________________________________________________
3. Was the patient receiving any of the following medications when influenza illness started? (check all that apply):
Aspirin or aspirin-containing products Systemic steroids (not inhaled) Radiation therapy
Chemotherapy for cancer
Other immunosuppressive medications (specify): __________________________
Isolation
Location 1:
Isolation Location: Home Hospital School Campus Unknown Other (specify): _____________________
Isolation Start Date: ( mm/dd/yyyy) _____/ _____/ _______ Isolation Discontinuation Date (mm/dd/yyy) _____/ _____/ _______
Location 2:
Isolation Location: Home Hospital School Campus Unknown Other (specify): _____________________
Isolation Start Date: (mm/dd/yyyy) _____/ _____/ _______ Isolation Discontinuation Date (mm/dd/yyy) _____/ _____/ ______
Contact and Travel During Infectious Period
1. Did the patient travel while ill? Yes No Unknown
2. Was the patient symptomatic during travel? Yes No Unknown
3. List all travel either by public conveyance (airplane, train, bus) or with a tour group, 24 hours before onset of fever or symptoms
thereafter. (List each portion of leg of the trip as a separate record):
Trip 1:
Depart Date: ______/ ______ / _________
Arrival Date: ______/ ______ / _________
Departure City: ______________________________________ Arrival City: ______________________________________
Transport Type: Airline Auto Bus Cruise Other Subway Tour Group Train
Trip 2:
Depart Date: ______/ ______ / _________
Arrival Date: ______/ ______ / _________
Departure City: ______________________________________ Arrival City: ______________________________________
Transport Type: Airline Auto Bus Cruise Other Subway Tour Group Train
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