Chart Abstraction Questionnaire for the Investigation of

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/2016

Chart Abstraction Questionnaire for the Investigation of Severe Neurologic Illness

in Relation to Arboviral Infections

Chart Abstractor: ____________________________ Abstraction Date: __ __ /__ __ /________

MRN: ____________________________ MM DD YYYY

Hospital: ____________________________

1. First name: _______________________________ Middle name: ______________________________

2. Paternal name: ____________________________ Maternal name: _____________________________

3. Age (years): ______________________________ Date of birth: __ __ /__ __ /________
   MM DD YYYY

4. Sex: □ Male □ Female

5. Patient address: ___________________________________________________________________________

6. Patient zip code: ____ ____ ____ ____ ____

7. Patient phone number: ______________________

8. Date of admission: __ __ /__ __ /________ Date first sought care: __ __ /__ __ /________
   MM DD YYYY MM DD YYYY

Date of discharge/death: __ __ /__ __ /________
MM DD YYYY

9. Discharged to:

□ Home (with outpatient PT: Yes / No) □ Rehab/skilled nursing facility □ Hospice

□ Transferred (specify hospital) ________________ □ Died □ Other (specify) _______________

10. 

    CURRENT ILLNESS

    Health insurance: □ Reforma/SSS □ Private □ Veteran’s □ None □ Other (specify) _______________

11. How long from onset until hospital admission? __________minutes/hours/days/weeks

12. What were the initial neurologic symptoms within the three days prior to illness onset? (check all that apply, signs from PE, symptoms from HPI)

□ Leg weakness □ Arm weakness □ Diplopia/Ophthalmoplegia

□ Leg numbness/paresthesias □ Arm numbness/paresthesias □ Face numbness/paresthesias

□ SOB / respiratory distress □ Gait imbalance (not weakness)/ataxia □ Hand clumsiness/ataxia
□ Hyporeflexia/areflexia □ Dysarthria □ Dysphagia □ Dysautonomia

□ Face weakness (circle: unilateral or bilateral)

13. What neurologic symptoms occurred AT ANY TIME during the neuro illness? (check all that apply, signs from PE, symptoms from HPI)

□ Leg weakness □ Arm weakness □ Diplopia/Ophthalmoplegia

□ Leg numbness/paresthesias □ Arm numbness/paresthesias □ Face numbness/paresthesias

□ SOB / respiratory distress □ Gait imbalance (not weakness)/ataxia □ Hand clumsiness/ataxia
□ Hyporeflexia/areflexia □ Dysarthria □ Dysphagia □ Dysautonomia

□ Face weakness (circle: unilateral or bilateral

14. Were motor deficits present? □ Yes □ No □ Unknown If so, describe:__________________________

15. Date of maximum/worst neuro symptoms: __ __ /__ __ /________

MM DD YYYY

16. At the worst point during this neuro illness, check all that apply for the patient:

□ Unable to walk without assistance □ Unable to walk at all □ Admitted to the hospital □ Admitted to the ICU/CCU □ Intubated □ Coma

17. Was there documented hyporeflexia/areflexia? □ Yes □ No □ Unknown

18. Was there documentation of upper motor neuron signs?

□ Hyperreflexia □ Increased tone/spasticity □ Babinski/Hoffman □ Sustained clonus

19. Was there any sensory level documented? □ Yes □ No □ Unknown

20. Did they receive any targeted treatment (IVIg/steroids/plasma exchange) for this neuro illness?

IVIg □ Yes □ No □ Unknown Start date __ __ /__ __ /________
MM DD YYYY
Plasma exchange □ Yes □ No □ Unknown Start date __ __ /__ __ /________
MM DD YYYY

Steroids □ Yes □ No □ Unknown Start date __ __ /__ __ /________
MM DD YYYY
Mechanical ventilation □ Yes □ No □ Unknown Start date __ __ /__ __ /________
MM DD YYYY

Acyclovir □ Yes □ No □ Unknown Start date __ __ /__ __ /________
MM DD YYYY

Other □ Yes □ No □ Unknown Start date __ __ /__ __ /________
MM DD YYYY

21. Did the patient receive blood transfusion/blood products (other than IVIg)?

□ Yes □ No □ Unknown If so, which: ______________ Start date __ __ /__ __ /________
MM DD YYYY

LABORATORY, IMAGING, AND ELECTROPHYSIOLOGIC STUDIES

22. If any blood was taken for this neurologic illness, please fill out the following for the INITIAL blood draw:

Date __ __ /__ __ /_______ WBC ____ HgB____ Plts _____ Na ____ K____
MM DD YYYY

BUN ____ Cr ______ Glucose____ TBili____ AST ____ ALT____ AlkPhos ___

23. Was a lumbar puncture (LP) done? □ Yes □ No □ Unknown

LP date ___/____/____ RBCS _______ WBCS ______ Protein (mg/dL)______ Glucose (mg/dL) _______
MM DD YYYY

Differential________________________IgG index______ Oligoclonal bands______ IgG synthesis___________

Opening pressure ___________________

Was an additional lumbar puncture (LP) done? □ Yes □ No □ Unknown

LP date ___/____/____ RBCS _______ WBCS ______ Protein (mg/dL)______ Glucose (mg/dL) _______
MM DD YYYY

Differential________________________IgG index______ Oligoclonal bands______ IgG synthesis___________

Opening pressure ___________________

24. Were any of the following pathogens tested for? If so, what was the result? (including specimen and type of test)

1. Campylobacter jejuni □ Yes □ No Result: _____________________________________

2. Mycoplasma pneumoniae □ Yes □ No Result: _____________________________________

3. Haemophilus influenzae □ Yes □ No Result: _____________________________________

4. Salmonella spp. □ Yes □ No Result: _____________________________________

5. Cytomegalovirus (CMV) □ Yes □ No Result: _____________________________________

6. Epstein-Barr virus (EBV) □ Yes □ No Result: _____________________________________

7. Varicella-zoster virus (VZV) □ Yes □ No Result: _____________________________________

8. Human immunodeficiency virus (HIV) □ Yes □ No Result: _____________________________________

9. Herpes simplex virus (HSV) □ Yes □ No Result: _____________________________________

10. Enterovirus / Rhinovirus □ Yes □ No Result: _____________________________________

11. Arboviruses □ Yes □ No Result: _____________________________________

12. Cryptococcus □ Yes □ No Result: _____________________________________

13. Toxoplasmosis □ Yes □ No Result: _____________________________________

14. Other: __________________________ □ Yes □ No Result: _____________________________________

15. Other: __________________________ □ Yes □ No Result: _____________________________________

16. Other: __________________________ □ Yes □ No Result: _____________________________________

17. Other: __________________________ □ Yes □ No Result: _____________________________________

18. Other: __________________________ □ Yes □ No Result: _____________________________________

19. Other: __________________________ □ Yes □ No Result: _____________________________________

25. Was neuro imaging done? If so, what was the result? (Transcribe the impression)

□ Yes □ No Result: _______________________________________________________________________

__________________________________________ Date __ __ /__ __ /________

MM DD YYYY

26. Were electro-diagnostics done (e.g. EMG)? If so, what were the results? (Transcribe the impression)

□ Yes □ No Result: _______________________________________________________________________

__________________________________________ Date __ __ /__ __ /________

MM DD YYYY

27. What was the GBS Brighton level? 1 2 3 4 5

ANTECEDENT ILLNESS

28. a.) In the 2 months prior to neuro onset date, did the individual experience an acute illness?

□ Yes □No □ Unknown

How long from prior acute illness onset until admission for neuro illness? _________ minutes/hours/days/weeks

29. b.) What symptoms did they report having or what signs were noticed? (check all that apply)

□ Fevers □ Chills □ Nausea or Vomiting □ Diarrhea □ Muscle pains □ Joint pains □ Skin rash □ Conjunctivitis

□ Headache □ Pain behind eyes □ Stiff neck □ Confusion □ Back pain

□ Abdominal pain □ Coughing □ Runny nose □ Sore throat □ Calf pain

c.) If any blood was taken for this acute illness, please fill out the following for the INITIAL blood draw:

Date __ __ /__ __ /________ WBC ____ HgB____ Plts _____ Na ____ K____
DD MM YYYY

BUN ____ Cr ______ Glucose____ TBili____ AST ____ ALT____ AlkPhos ___

d.) Were they hospitalized for this acute illness? □ Yes □ No □ Unknown

e.) Did they receive any blood products / IVIg for this illness? □ Yes □ No □ Unknown

What product? _____________________ Date? __ __ /__ __ /________
MM DD YYYY

g.) Did they receive plasmapheresis / plasma exchange for this illness? □ Yes □ No □ Unknown

If yes, date? __ __ /__ __ /________
MM DD YYYY

30. Is there a test result available for dengue from this medical visit? □ Yes □ No □ Unknown

31. Is there a test result available for chikungunya from this medical visit? □ Yes □ No □ Unknown

32. Is there a test result available for Zika from this medical visit? □ Yes □ No □ Unknown

33. 

    PAST MEDICAL, SOCIAL, AND FAMILY HISTORY

    What medical conditions are listed in the admission history and physical (H&P)?

□ Hypertension □ Diabetes □ HIV □ Syphilis □ Autoimmune disorder____________

□ B12 deficiency □ Hemoglobinopathy □ Prior GBS □ Cancer _______________________

34. What conditions are listed in family history of H&P?

□ Autoimmune disorder (specify): ___________________ □ Cancer (specify): _____________________

□ Hemoglobinopathy (specify): _____________________ □ Neuro (specify): ______________________

35. What social conditions are listed in admission H&P?

□ Alcohol use □ Drug use □ Tobacco □ Other ________________________

36. Did the patient receive a vaccine in the previous 6 months? □ Yes □ No □ Unknown

OTHER NEUROLOGIC CONDITIONS

If yes, vaccine: _________________ Date of vaccination: __ __ /__ __ /________
MM DD YYYY

37. What other neurologic conditions were identified by the provider?

□ ADEM □ CIDP □ Encephalitis □ Encephalomyelitis □ Facial paralysis

□ Meningoencephalitis □ Myasthenia gravis □ Myelitis □ Myelopathy

□ Multiple sclerosis (MS) □ Neuropathy □ Optic neuritis □ Paresthesia

□ Papilledema □ Transverse myelitis □ Sensory motor peripheral neuropathy

□ Stroke □ Other: _________________________________________________________

38. Additional signs or symptoms not already noted:

□	Agitation	□	Altered lacrimal gland secretion	□	Altered mental status	□	Altered salivary gland secretion
□	Aphasia	□	Confusion	□	Drooping corner of mouth	□	Eye pain
□	Eyebrow sagging	□	Fatigable chewing	□	Fever	□	Headache
□	Inability to close eye	□	Irritability	□	Lethargy	□	Lower extremity dysthesesia
□	Loss of taste anterior 2/3 of tongue	□	Memory loss	□	Nausea	□	Nasolabial fold disappearance
□	Nuchal rigidity	□	Nystagmus	□	Oculomotor deficits	□	Personality changes
□	Ptosis	□	Seizures	□	Sensory deficits:	□	Somnolence
					______________________
□	Transient visual obscuration	□	Tremors	□	Upper extremity dysthesesia	□	Urinary retention
□	Vision loss	□	Vomiting	□	Other: _________________	□	Other: ___________________

Public reporting burden of this collection of information is estimated to average 60 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-XXXX)