Form 23 Attachment 8 Form 6a Medical History

Form Approved  
 OMB Number 0925‐XXXX 
Exp. Date: XX/XX/XXX 
Public reporting burden for this form is estimated to average 10 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: NIH, Project Clearance Branch, 6705 
Rockledge Drive, MSC 7974, Bethesda, MD 20892‐7974, ATTN: PRA (0925‐XXXX). Do not return the completed form to this 
address. 
Study ID: __ __ __ __ __ __ __ __ __ __
CEIRS Human Influenza Surveillance Study
Form 6A: Medical History
The following questions are about the subject’s recent medical care and medications.
1. ED arrival
Arrival Date: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)
Arrival Time: __ __ : __ __ (hh:mm) (24-hour clock)
2. Has the subject been admitted to the hospital (i.e. stayed overnight) within the past 30 days?

□ No □ Yes □ Unknown
If Yes,
a. For how many days was the subject admitted?
__________Days
b. When was the subject discharged?
_____/_____/________ (mm/dd/yyyy)
3. Has the subject taken any antibiotics within the past 30 days?

□ No □ Yes □ Unknown
a. If Yes, how many antibiotics were taken?

__________Antibiotics

For each antibiotic received, specify the antibiotic name, date started, days taken, and condition it was prescribed
for (i.e. indication; If unknown, please write “unknown”).

Antibiotic 1
Name: _____________________________________
Date started: _____/_____/_______ (mm/dd/yyyy)
Days taken for: __________________________Days
Indication: __________________________________

Antibiotic 3
Name: _____________________________________
Date started: _____/_____/_______ (mm/dd/yyyy)
Days taken for: __________________________Days
Indication: __________________________________

Antibiotic 2
Name: _____________________________________
Date started: _____/_____/_______ (mm/dd/yyyy)
Days taken for: __________________________Days
Indication: __________________________________

Antibiotic 4
Name: _____________________________________
Date started: _____/_____/_______ (mm/dd/yyyy)
Days taken for: __________________________Days
Indication: __________________________________

Page 1 of 5

Form 6A: Medical History

Version 2.0
01/05/2015

Study ID: __ __ __ __ __ __ __ __ __ __
4. Has the subject taken any influenza antivirals within the past 30 days?

□ No □ Yes □ Unknown
Examples are: Oseltamivir (Tamiflu), Zanamivir (Relenza), Amantadine (Symmetrel), or Rimantadine
(Fluadine)
If Yes,
a. Name of influenza antiviral
b. Date the subject started the antiviral: _____/_____/_______ (mm/dd/yyyy)
c. How many days did the subject take the antiviral for? __________Days
5. Is the subject currently taking steroids (pill or injections)?

□ No □ Yes □ Unknown
If Yes, how many steroids is the subject taking? ___________Steroids
For each steroid, specify the steroid name and dose.
Steroid 1
Name: _________________________
Dose: _________________________
Steroid 2
Name: _________________________
Dose: _________________________
Steroid 3
Name: _________________________
Dose: _________________________
Steroid 4
Name: _________________________
Dose: _________________________
6. Is the subject taking any medications that suppress their immune system?

□ No □ Yes □ Unknown
If Yes, which medications (Check all that apply*)
_____ Methotrexate
_____ Tacrolimus (Propgraf)
_____ Mycopehnolate (Cellcept)
_____ Other, specify: ____________________
* Please see Appendix 4 for a list of additional immunosuppressive medications

Page 2 of 5

Form 6A: Medical History

Version 2.0
01/05/2015

Study ID: __ __ __ __ __ __ __ __ __ __
Medical History
The next few questions are about the subject’s overall medical history.
7. Does the subject have Chronic Lung Disease?

□ No □ Yes □ Unknown

If Yes, does the subject have:

□ No □ Yes □ Unknown
□ No □ Yes □ Unknown
□ No □ Yes □ Unknown

Asthma?
COPD?
Cystic Fibrosis?

Other, specify: ____________________________
8. Does the subject have any Cardiovascular Disease?

□ No □ Yes □ Unknown
If Yes, does the subject have:

□ No
□ No
□ No
□ No
□ No

Coronary Artery Disease?
Congestive Heart Failure?
Cardiomyopathy?
Vascular Disease?
Congenital Heart Disease?

□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown

Other, specify: _____________________________

□ No □ Yes □ Unknown

9. Does the subject have Renal Disease?
If Yes, does the subject have:

□ No □ Yes □ Unknown

End Stage Renal Disease?

Other, specify: _____________________________
10. Does the subject have any Hepatic Disease?

□ No □ Yes □ Unknown

If Yes, does the subject have:
Cirrhosis?
Hepatitis B?
Hepatitis C?

□ No □ Yes □ Unknown
□ No □ Yes □ Unknown
□ No □ Yes □ Unknown

Other, specify: _____________________________
11. Does the subject have any Endocrine/ Metabolic Disorders?

□ No □ Yes □ Unknown
If Yes, does the subject have:
Diabetes?
Thyroid Disorder?

□ No □ Yes □ Unknown
□ No □ Yes □ Unknown

Other, specify: ___________________________

Page 3 of 5

Form 6A: Medical History

Version 2.0
01/05/2015

Study ID: __ __ __ __ __ __ __ __ __ __
12. Does the subject have any Hematological Disease?

□ No □ Yes □ Unknown
If Yes, does the subject have:

□ No □ Yes □ Unknown
□ No □ Yes □ Unknown
□ No □ Yes □ Unknown

Sickle Cell Disease?
Lymphoma?
Leukemia?

Other, specify: ___________________________
13. Does the subject have any Neurological Disorders?

□ No □ Yes □ Unknown
If Yes, does the subject have:

□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No

Stoke?
Seizure/Epilepsy?
Intellectual Disability?
Multiple Sclerosis?
Muscular Dystrophy?
Spinal Cord Disease or Injury?
Peripheral Nerve Disease?
Cerebral Palsy?

□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown

Other, specify: ___________________________

□ No □ Yes □ Unknown

14. Does the subject have HIV/AIDS?

If Yes, does the subject have a recent (within the last 12 months) CD4 count?

□ No □ Yes □ Unknown
If Yes, what is their most recent:
CD4 count? ____________
Date of CD4 count: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)
15. Does the subject have an autoimmune disorder?

□ No

□ Yes □ Unknown

If Yes, specify autoimmune disorder: _________________________________

Page 4 of 5

Form 6A: Medical History

Version 2.0
01/05/2015

Study ID: __ __ __ __ __ __ __ __ __ __
16. Does the subject have/has the subject had Cancer?

□ No □ Yes □ Unknown
If Yes, specify Cancer: _____________________
Is the subject on Chemotherapy?

□ No □ Yes □ Unknown

How many medications is the subject taking? (List up to 5)
Specify medications received and date of last dose:
Medication 1: _______________________ Date: __ __ / __ __ / __ __ __ __
Medication 2: _______________________ Date: __ __ / __ __ / __ __ __ __
Medication 3: _______________________ Date: __ __ / __ __ / __ __ __ __
Medication 4: _______________________ Date: __ __ / __ __ / __ __ __ __
Medication 5: _______________________ Date: __ __ / __ __ / __ __ __ __
17. Has the subject had an Organ Transplant?

□ No □ Yes □

Unknown

If Yes, specify organ: __________________________________
18. Has the subject suffered any other medical conditions not mentioned above?

□ No □ Yes □ Unknown
If Yes, specify: _________________________________________________________

Page 5 of 5

Form 6A: Medical History

Version 2.0
01/05/2015