Zika Virus Disease Enhanced Surveillance – Hospitalizati

Form Approved

OMB Control No. 0920-XXXX

Exp. date: XX/XX/XXXX

Attachment 5: Zika Virus Disease Enhanced Surveillance – Hospitalization associated with Zika virus disease

Demographic Information
Case ID (ArboNET):_____________________ Control for Case ID:____________________ State of residence:_____________________ County of residence:___________________ Age: ______  Years  Months  Days Sex:  Male  Female Pregnant:  Yes  No  Unknown Est Date Delivery: ____/____/____ OR Last Menstrual Period: ____/____/____ Race (Select all appropriate):  American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian or Other Pacific Islander  White  Other  Unknown Ethnicity:  Hispanic or Latino  Not Hispanic or Latino  Unknown Imported From:  Not Imported  Acquired Out of State  Acquired Out of Country  Unknown Country of Origin:________________________________ Travel dates:____________________________ State of Origin:__________________________________ Travel dates: ____________________________ Other possible exposures:  Sexual  Breastfeeding  Blood products  Organs
Past Medical History
Hypertension		 Yes  No  Unk
Heart disease		 Yes  No  Unk
Diabetes mellitus		 Yes  No  Unk
Asthma/respiratory disease		 Yes  No  Unk Specify:_________________________________________
COPD		 Yes  No  Unk
Autoimmune disorder		 Yes  No  Unk
Cancer		 Yes  No  Unk
Other immune deficiency		 Yes  No  Unk
Liver/hepatic disease		 Yes  No  Unk
Kidney/renal disease		 Yes  No  Unk
Thyroid disease		 Yes  No  Unk
Seizure disorder		 Yes  No  Unk
Other neurologic disease		 Yes  No  Unk Specify:_________________________________________
Tobacco use		 Yes  No  Unk If yes:  Current  Past
Alcoholism		 Yes  No  Unk
Intravenous drug use		 Yes  No  Unk If yes:  Current  Past
Other medically important condition		 Yes  No  Unk Specify:_________________________________________
Pre-existing Medications and Treatments
Medications to treat hypertension				 Yes  No  Unk
Medications to treat coronary heart disease				 Yes  No  Unk
Medications to treat congestive heart failure				 Yes  No  Unk
Chemotherapy				 Yes  No  Unk
Other treatments for cancer				 Yes  No  Unk
Medications that suppress the immune system				 Yes  No  Unk
Insulin or other meds to treat diabetes				 Yes  No  Unk
Hemodialysis				 Yes  No  Unk
Other treatments for kidney disease				 Yes  No  Unk
Oral or injected steroids				 Yes  No  Unk
Clinical Information
Illness onset date: _____/_____/_____
Clinical syndrome:  Febrile illness  Encephalitis/meningoencephalitis  Meningitis  Acute flaccid paralysis  Guillain-Barré syndrome  Other neuroinvasive presentation  Other clinical
Case Status (ArboNET):  Confirmed  Probable
Fever	 Yes  No  Unk  Subjective  Measured (Max temperature: __________)
Chills/Rigors	 Yes  No  Unk
Rash	 Yes  No  Unk Type:  Maculopapular  Petechial  Purpuric  Other:____________________________________________ Pruritic:  Yes  No  Unk Distribution:­­­­­­­_______________________________________________
Headache	 Yes  No  Unk
Retro-orbital pain	 Yes  No  Unk
Conjunctivitis	 Yes  No  Unk
Oral ulcers	 Yes  No  Unk
Nausea/Vomiting	 Yes  No  Unk
Diarrhea	 Yes  No  Unk
Arthralgia	 Yes  No  Unk
Arthritis	 Yes  No  Unk
Myalgia	 Yes  No  Unk
Paresis/Paralysis	 Yes  No  Unk
Stiff Neck	 Yes  No  Unk
Ataxia	 Yes  No  Unk
Altered mental status	 Yes  No  Unk
Seizures	 Yes  No  Unk
Sore throat	 Yes  No  Unk
Cough	 Yes  No  Unk
Lymphadenopathy	 Yes  No  Unk
Paresthesia	 Yes  No  Unk
Abdominal pain	 Yes  No  Unk
Edema	 Yes  No  Unk Specify:__________________________________________________
Other	 Yes  No  Unk Specify:__________________________________________________
Outcomes
Emergency department	 Yes  No  Unk
Hospitalized	 Yes  No  Unk					Admission: ____/____/____ Discharge:____/____/____ Days hospitalized:______________ Multiple admissions:  Yes  No  Unk Number:__________
ICU	 Yes  No  Unk					Admission: ____/____/____ Discharge:____/____/____ Days in intensive care:____________ Intubation:  Yes  No  Unk
Admission diagnoses	Primary diagnosis or ICD 10:________________________________________________________ Additional diagnoses:_____________________________________________________________
Outcomes (continued)
Discharge diagnoses	Primary diagnosis or ICD 10:________________________________________________________ Additional diagnoses:_____________________________________________________________
Died	 Yes  No  Unk					Date of Death:_____/_____/_____ Causes of death: 1.________________________________________ 2.________________________________________ 3.________________________________________
Discharged to rehab	 Yes  No  Unk
Treatments Administered During Hospitalization
Antimicrobials			 Yes  No  Unk Specify:________________________________________
Steroids/other immune modulating			 Yes  No  Unk Specify:________________________________________
Blood products			 Yes  No  Unk Specify:________________________________________
Zika Virus Test Results							Dengue Virus Test Results
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial							Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial							Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial							Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial							Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial
Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial							Specimen collected: _____/_____/_____ Specimen Type:  Serum  CSF  Urine Test:  IgM  PRNT  PCR/NAT  IHC Result:  Positive  Negative  Equivocal Performing Lab:  CDC  State PH  Commercial
Laboratory Tests
CBC performed  Yes  No  Unk
	Leukopenia (<4,500) Thrombocytopenia (<150,000) Leukocytosis (>11,000)						 Yes  No  Unk  Yes  No  Unk  Yes  No  Unk		Nadir:_____ ; Date:__­­­­__/___/____ Nadir:_____ ; Date:__­­­­__/___/____ Max:______ ; Date:__­­­­__/___/____
Abnormal liver enzymes	AST:  Yes  No  Unk Max:_______; Date:__­­­­__/____/____ ALT:  Yes  No  Unk Max:_______; Date:__­­­­__/____/____
LP performed	 Yes  No  Unk				Date:___/____/____ WBC:_____________ RBC:______________ Protein:___________ Glucose:___________			Date:___/____/____ WBC:_____________ RBC:_____________ Protein:___________ Glucose:__________		Date:___/____/____ WBC:_____________ RBC:_____________ Protein:___________ Glucose:__________
MRI	 Yes  No  Unk				Date:___/____/____			Abnormal results:  Yes  No  Unk If yes, describe:________________________ _____________________________________
CT	 Yes  No  Unk				Date:___/____/____			Abnormal results:  Yes  No  Unk If yes, describe:________________________ _____________________________________
EMG/NCS	 Yes  No  Unk				Date:___/____/____			Abnormal results:  Yes  No  Unk If yes, describe:________________________ _____________________________________
Other test	 Yes  No  Unk				Date:___/____/____			Abnormal results:  Yes  No  Unk If yes, describe:________________________ _____________________________________

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