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pdfPossible Human Rabies - Patient Information Form
Please print the following form and fill it out as completely as possible. A copy of this form must
accompany diagnostic specimens. Send completed form with samples
to:
Rabies Laboratory
DASH, Bldg 18, Rm SSB218
Centers for Disease Control and Prevention
1600 Clifton Rd, NE
Atlanta, GA 30333
and/or
Fax: Attn: Rabies Duty Officer
404-639-1564
Physician Contact Information
Send Report to
Physician's Name
Please indicate person to receive official report of results
Physician's Contact Number
Fax Number
Hospital
City
Email Address
State
Patient Information
Patient ID (for reporting results)
Gender
Date of Birth
First Symptoms
Occupation
Date of Ilness Onset
Hospitalized
Outpatient Visit Date
Date Hospitalized
Outpatient Diagnosis
Admiting Diagnosis
Is/was the patient in a coma
Yes
No
Yes
Has the patient expired
Date of coma onset
No
Yes
Date of Death
Current differential diagnosis
Samples Submitted
All four samples are
required to provide an
antemortem rule out of
rabies.
Please provide date(s) of
collection for each sample.
Date 1
Nuchal biopsy
Saliva
Serum
CSF
Date 2
Date 3
Date 4
No
1/3
Possible Human Rabies - Patient Information Form
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Symptoms
Which of the following symptoms have been present? Mark all that apply.
Fever
Yes
No
Unknown
Aerophobia
Yes
No
Unknown
Malaise
Yes
No
Unknown
Hydrophobia
Yes
No
Unknown
Headache
Yes
No
Unknown
Localized Weakness
Yes
No
Unknown
Nausea / Vomiting
Yes
No
Unknown
Localized Pain / Parasthesia
Yes
No
Unknown
Anxiety
Yes
No
Unknown
Confusion or delirium
Yes
No
Unknown
Muscle Spasm
Yes
No
Unknown
Agitation / Combativness
Yes
No
Unknown
Dysphagia
Yes
No
Unknown
Autonomic instability
Yes
No
Unknown
Anorexia
Yes
No
Unknown
Hyperactivity
Yes
No
Unknown
Ataxia
Yes
No
Unknown
Hallucinations
Yes
No
Unknown
Priapism
Yes
No
Unknown
Insomnia
Yes
No
Unknown
Seizures
Yes
No
Unknown
Hypersalivation
Yes
No
Unknown
Laboratory Findings
Peripheral WBC (with diff)
On Admission
Chemistry
x103/ul
Neutrophils
%
lymphocytes
%
monocytes
%
bands
%
Highest
x103/ul
Neutrophils
%
lymphocytes
%
monocytes
%
bands
%
Culture results
Additional abnormal
Laboratory Values
Additional Pertinent
Clinical Information /
Diagnostic results
CSF Findings
Glucose, serum
mg/dl
RBC
/ul
Total Protein, serum
g/dl
WBC
/ul
CPK, serum - total
U/l
Neutrophils
%
Isoenzymes - MM
%
Lymphocytes
%
MB
%
Monocytes
%
BB
%
bands
%
Glucose
mg/dl
Protein
mg/dl
Possible Human Rabies - Patient Information Form
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Additional Information
Patient Residence and Travel
Location of residence at time of onset
City
Suburban
Urban
Rural
State
Has the Patient traveled to any foreign country in the past 6 months?
Country 1
Number of days
Country 2
Number of days
Animal Exposure
Any suspicious animal exposures?
Yes
No
*Most Recent exposure
City
State
Date of exposure
Species involved in most recent exposure
Type of exposure
Dog
Bite
Cat
Nonbite (scratch)
Raccoon
Nonbite (contact only)
Skunk
No known exposure
Fox
Unknown
Bat
Other
specify
*Previous exposure
City
State
Date of exposure
Species involved in previous exposure
Type of exposure
Dog
Bite
Cat
Nonbite (scratch)
Raccoon
Nonbite (contact only)
Skunk
No known exposure
Fox
Unknown
Bat
Other
specify
| File Type | application/pdf |
| File Modified | 2010-03-22 |
| File Created | 2010-03-22 |