Form 0920-1170 Case Questionnaire

Canine Leptospirosis Surveillance in Puerto Rico

Att E - Case Questionnaire ENGLISH

Case Questionnaire - Dog Owner

OMB: 0920-1170

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Form Approved

OMB No. 0920-1170

Expires 03/31/2019

CANINE LEPTOSPIROSIS SURVEILLANCE

CASE QUESTIONNAIRE



Study Case ID:


Clinic/Shelter Patient Record ID:




Place pre-printed label here






Date: _____ /_____ /_____ (MM, DD, YY)

Clinic / Shelter Name: _________________________________________ Facility type:

Vet / Staff Name: _____________________________________________ ☐ Clinic ☐ Shelter

Section 1. General Information

Owner Information

Does the dog have an owner? Yes No (stray) Unknown

If yes, Last Name: ____________________ First Name: _________________________

Address of owner or stray pick-up location:

Street Address (or major intersection): ________________________________________________________________

City: _______________________________ Municipality: ____________________________ Zip Code: ___________

Signalment

Dog’s Name: _________________ Age: _____ Yr Mo Sex: Male Female Spayed/Neutered? Yes No

Breed: Mix Purebred Breed (if known): __________________________ __ Weight: _________ lbs kg

Section 2. Risk Factors and Exposures

Check all that apply (unless otherwise indicated):

Is the dog a: Pet Neighborhood dog Watchdog Hunting dog Herding dog Other: _______________

Where does the dog spend his/her time (pick one)?

Mostly indoors Mostly outdoors 50% indoors / 50% outdoors Always outdoors

When outdoors, in what area does the dog spend time (pick one)?

Fenced yard Allowed to roam Both areas

Does the dog drink water from:

Inside house Outside house Puddles Lake/pond River/stream Other: __________________

Does the dog eat food: Inside house Outside house Other: ___________________________________

Does the dog sleep: Inside house Outside house Other: ___________________________________

Does the dog have contact with:

Owned dogs Stray dogs Rodents Livestock: __________ Wildlife: __________ Other: ___________

In the last 30 days, has the dog swum in: River/stream Lake/pond Puddle

In the last 30 days, has the dog traveled outside of the city of residence?

Yes, where? _________________________________ No Unknown

In the last 30 days, has the dog had contact with a sick dog diagnosed with leptospirosis? Yes No Unknown

Have rodents or evidence of rodents (feces, eaten food stores, holes) been seen in the house? Yes No Unknown

Have rodents or evidence of rodents been seen in other areas where the dog lives/goes?

Yes, where? _________________________________ No Unknown

Has the dog had a previous diagnosis of leptospirosis? Yes, date: ____ /____ /____ (MM, DD, YY) No Unknown

Has the dog been vaccinated against leptospirosis? Yes No Unknown

If yes, , Date of vaccination: ____ /____ /____ (MM, DD, YY) Vaccine Name:___________________________________



Section 3. Clinical and Laboratory Information

Signs and Symptoms

Date of symptom onset: ____ /____ /____ (MM, DD, YY)

What clinical signs have occurred since symptom onset?

Provide one response for each line.

Fever Yes, Temp: ________°C No Unk

Lethargy/weakness Yes No Unk

Inappetence/anorexia Yes No Unk

Vomiting Yes No Unk

Diarrhea Yes No Unk

Abdominal pain Yes No Unk

Muscle/joint tenderness Yes No Unk

Conjunctivitis/red eyes Yes No Unk

Icterus/yellow skin or eyes Yes No Unk

Cough Yes No Unk

Tachypnea/dyspnea Yes No Unk

Oliguria/anuria Yes No Unk

Polyuria/polydipsia Yes No Unk

Renal failure/insufficiency Yes No Unk

Liver failure/elevated enzymes Yes No Unk

Uveitis Yes No Unk

Altered mentation Yes No Unk

Abortion Yes No Unk

Pulmonary hemorrhage Yes No Unk

Other bleeding Yes, _________________ No

Other signs/symptoms Yes, _________________ No

Specimens collected:

Date: _____/_____/____

Serum

Blood

Urine – cystocentesis

Urine - free catch

Kidney tissue


Laboratory Results

Lepto Rapid Test 1:

Date: ____/____/____

Negative

Positive


Perform test #2 if the first lepto rapid test was negative and blood was collected <7 days after symptom onset.


Lepto Rapid Test 2:

Date: ____/____/____

Negative

Positive









If other lepto tests were done, please record results:

IDEXX lepto snap:

Pos Neg Invalid

Zoetis WITNESS lepto:

Pos Neg Invalid








Other Lab Tests Done:

Hematology Biochemistry Urinalysis

Attach a copy of the lab report OR fill in lab values below:

Creatinine: Norm High Low

BUN: Norm High Low

ALT: Norm High Low

AST: Norm High Low

ALP: Norm High Low

Bilirubin: Norm High Low

Albumin: Norm High Low

CPK: Norm High Low

K: Norm High Low

HCT = __________%

Platelet: Norm High Low

WBC: Norm High Low

Neutrophil: Norm High Low

Lymphocyte: Norm High Low

Urine specific gravity = ____________














Hospitalization status and outcome:

Was the dog hospitalized? Yes, # of days: ______ No

Outcome: Discharged Died Unknown

If died, was it due to: Euthanasia Unassisted/natural death

Were antibiotics prescribed? Yes No

If yes, # of days prescribed: ___________ ; Name of antibiotic(s):____________________________________

Send a copy of this form by fax to 404-471-8642 OR by email to [email protected] OR with monthly shipments to CDC.

Thank you!



Public reporting burden of this collection of information is estimated to average 15 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-1170).


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