Dengue and Chikungunya Report

Form Approved
OMB No. 0920-1011
Exp. Date 03/31/2017

Dengue and chikungunya report form

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer;
1600 Clifton Road NE, MS D-74 Atlanta, Georgia 30333; ATTN: PRA (0920-1011)

DENGUE & CHIKUNGUNYA REPORT FORM
U.S. Virgin Islands Department of Health
Charles Harwood Complex, 3500 Estate Richmond
Christiansted, St. Croix, USVI 00820-4370
Tel. (340) 773-1311 x3241, Fax (340) 718-1508

Case number

Specimen #

SAN ID

GCODE

Days post onset (DPO) Type

Date Received

S3

S2

S4

No

Today’s date: _______________
Day/Month/Year

Specimen #

S1

SUSPECTED CHIK? Yes

Days post onset (DPO)

Type

Date Received

Please read and complete ALL sections
Patient Data

Hospitalized due to this illness: No

→ Hospital Name:

Yes

Record Number:
Fatal:

Name of Patient:
Last Name

First Name

Yes

Middle Name or Initial

No

Unk

Mental status changes:

If patient is a minor, name of father or primary caregiver:
Last Name

First Name

Home (Physical) Address

Middle Name or Initial

Yes

No

Unk

Physician who referred this case

Home address here

Name of Healthcare Provider:
Tel:

Fax:

Email:

Do you want to receive laboratory results via Fax or Email?
City:

Zip code:

Tel:

-

Other Tel:

Residence is close to:
Work address:

Patient’s Demographic Information

Date of Birth:

Age:

months Sex:

or Age:

years

Who filled out this form?
M

F

Pregnant: Y

N

UNK

Weeks pregnant (gestation):

Day/Month/Year

Name (complete)
Relationship with patient:
Tel:

Fax:

Email:

Must have the following information for sample processing
Day/Month/Year

Country of birth

How long have you lived in this city?

Date of first symptom:

During the 14 days before onset of illness, did you TRAVEL to other cities or countries?

Date specimen taken:
First sample

Yes, another country

Yes, another city

No

Unknown

WHERE did you TRAVEL?

Second sample

Are there any sick contacts in your household?
Yes

No

PLEASE indicate below the signs and symptoms that the patient had at the time of illness
Yes

No

Unk

Evidence of capillary leak
Lowest

Fever lasting 2-7 days……………......
Fever (>38ºC/101ºF)………………......
Platelets ≤100,000/mm3………..….....

Warning signs

hematocrit

Highest

hematocrit

Lowest

serum

(%)

Persistent vomiting...................................

(%)

Abdominal pain/Tenderness…………..

albumin

Mucosal bleeding …………………….....

Lowest serum protein

Lethargy, restlessness……….…………...

Platelet count:

Lowest blood pressure (SBP/DBP)

Any hemorrhagic manifestation
Petechiae………………………..

Lowest pulse pressure (systolic - diastolic)

Liver enlargement >2cm………………..

/

Pleural or abdominal effusion………….

Lowest white blood cell count (WBC)

Purpura/Ecchymosis…………..

Symptoms

Yes

Yes

Additional symptoms
No

Unk

Diarrhea……………………………...……..

Vomit with blood……………….

Rapid, weak pulse……………...

Blood in stool……………………

Cough…………………………………….…

Pallor or cool skin……………….

Nasal bleeding…………………

Conjunctivitis……………………………....

Chills………………………….……

Nasal congestion…………………………

Rash…...........................................

Sore throat………………………………....

Headache……………….……….

Jaundice………………………..................

Eye pain…………………………..

Convulsion or coma……………………..

Body (muscle/bone) pain…….

Nausea and vomiting (occasional)…..

Joint pain…………………………

Arthritis (Swollen joints)…………………..

Anorexia……………………….....

Missed school/work due to this illness.

Bleeding gums………………….
Blood in urine…………………...
Vaginal bleeding………………
Positive urinalysis……………....
(over 5 RBC/hpf or positive for blood)
Tourniquet test

Pos

Neg

Not done

Unable to walk during this illness……..

No

Unk