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pdfVIRAL HEPATITIS CASE REPORT
The following questions should be asked for every case of viral hepatitis
Form Approved OMB No. 0920-0728 Exp. Date 02/28/2021
Prefix: (Mr. Mrs. Miss Ms. etc) _____ Last: __________________________________ First: __________________________ Middle: _________________________
Preferred Name (nickname): _____________________________________________ Maiden: ____________________________________________________________
Address: Street: ____________________________________________________________________________________________________________________________
City: __________________________________________ Phone: ( __ __ __ ) __ __ __ – __ __ __ __ Zip Code: __ __ __ __ __ – __ __ __ __
SSN # (optional) __ __ __ – __ __ __ – __ __ __ __
Only data from lower portion of form will be transmitted to CDC
MM
D __
D / __
Y __
Y __
Y __
Y
State: _________________ County:____________________________________________________ Date of Public Health Report __
__ / __
Case ID: ______________________________________________________
Legacy Case ID:________________________________________________
DEMOGRAPHIC INFORMATION
RACE: (check all that apply)
ETHNICITY:
❑ Amer Indian or Alaska Native
❑ Black or African American
❑ White
Hispanic................................. ❑
❑ Asian
❑ Native Hawaiian or Pacific Islander
❑ Other Race, specify _______________
Non-hispanic ......................... ❑
SEX: Male ❑
Female ❑
PLACE OF BIRTH: ❑ USA
Unk ❑
M __
M / __
D __
D / __
Y __
Y __
Y __
Y
DATE OF BIRTH: __
❑ Other: _________________
Other/Unknown..................... ❑
AGE: __ __ __ (years) (00 = <1yr , 999 = Unk)
CLINICAL & DIAGNOSTIC DATA
REASON FOR TESTING: (check all that apply)
❑ Year of birth (1945-1965)
❑ Symptoms of acute hepatitis
❑ Prenatal screening
❑ Screening of asymptomatic patient with reported risk factors
❑ Blood/organ donor screening
❑ Unknown
❑ Screening of asymptomatic patient with no risk factors (e.g., patient requested)
❑ Evaluation of elevated liver enzymes
❑ Follow-up testing for previous marker of viral hepatitis
❑ Other: specify: _____________________________
CLINICAL DATA:
DIAGNOSTIC TESTS: (CHECK ALL THAT APPLY)
M __
M / __
D __
D / __
Y __
Y __
Y __
Y
Diagnosis date: __
Yes
No
Unk
❑
❑
❑
Is patient symptomatic? ................................................
M __
M / __
D __
D / __
Y __
Y __
Y __
Y
if yes, onset date: __
At diagnosis, was the patient
• Total antibody to hepatitis A virus [total anti-HAV] ..............
Pos
Neg
Unk
❑
❑
❑
• IgM antibody to hepatitis A virus [IgM anti-HAV].................
❑
❑
❑
• Hepatitis B surface antigen [HBsAg] ......................................
❑
❑
❑
• Jaundiced? ..............................................................
❑
❑
❑
• Total antibody to hepatitis B core antigen [total anti-HBc].....
❑
❑
❑
• Hospitalized for hepatitis? ......................................
❑
❑
❑
• Hepatitis B “e” antigen [HBeAg] ............................................
❑
❑
❑
Was the patient pregnant? .............................................
❑
❑
❑
• IgM antibody to hepatitis B core antigen [IgM anti-HBc] ......
❑
❑
❑
• Nucleic Acid Testing for hepatitis B [Hep B NAT]..................
❑
❑
❑
• Antibody to hepatitis C virus [anti-HCV] ...............................
❑
❑
❑
M __
M / __
D __
D / __
Y __
Y __
Y __
Y
Due date: __
Did the patient die from hepatitis? ................................
❑
❑
❑
MM
D __
D / __
Y __
Y __
Y __
Y
• Date of death: __
__ / __
– anti-HCV signal to cut-off ratio ______
Was the patient aware they had viral hepatitis
prior to lab testing? .......................................................
• Supplemental anti-HCV assay [e.g., RIBA] ........................
❑
❑
❑
❑
• Antibody to hepatitis D virus [anti-HDV] ..............................
❑
❑
❑
❑
Does the patient have a provider of care for hepatitis? ...
❑
❑
Does the patient have diabetes? .....................................
❑
❑
• Antibody to hepatitis E virus [IgM anti-HEV]........................
❑
❑
❑
❑
❑
❑
If this case has a diagnosis of hepatitis A that has not been
serologically confirmed, is there an epidemiologic link between
this patient and a laboratory-confirmed hepatitis A case?
Yes
No
Unk
❑
❑
❑
M __
M / __
D __
D / __
Y __
Y __
Y __
Y
Diabetes diagnosis date: __
LIVER ENZYME LEVELS AT TIME OF DIAGNOSIS
• ALT [SGPT] Result _________
Upper limit normal _________
M __
M / __
D __
D / __
Y __
Y __
Y __
Y
• Date of ALT result __
• AST [SGOT] Result _________
Upper limit normal _________
M __
M / __
D __
D / __
Y __
Y __
Y __
Y
• Date of AST result __
DIAGNOSIS: (check all that apply)
❑ Acute hepatitis A
❑ Acute hepatitis C
❑ Chronic HBV infection
❑ Acute hepatitis B
❑ HCV infection (Past or Present)
❑ Acute hepatitis E
1
❑ Perinatal HBV infection
CS239580-A
Patient History — Acute Hepatitis A
Case ID: _______________________________________________
Yes
No
Unk
❑
❑
❑
• household member (non-sexual) ....................................................................................................................................................
❑
❑
❑
• sex partner .....................................................................................................................................................................................
❑
❑
❑
• child cared for by this patient.........................................................................................................................................................
❑
❑
❑
• babysitter of this patient ................................................................................................................................................................
❑
❑
❑
• playmate ........................................................................................................................................................................................
❑
❑
❑
• a child or employee in a day care center, nursery, or preschool? .....................................................................................................
❑
❑
❑
• a household contact of a child or employee in a day care center, nursery or preschool? .................................................................
❑
❑
❑
If yes for either of these, was there an identified hepatitis A case in the child care facility? .............................................................
❑
❑
❑
During the 2-6 weeks prior to onset of symptomsWas the patient a contact of a person with confirmed or suspected hepatitis A virus infection? .........................................................
If yes, was the contact (check one)
• other __________________________
Was the patient
What is the sexual preference of the patient?
❑ Heterosexual
❑ Homosexual
❑ Bisexual
❑ Unknown
Please ask both of the following questions regardless of the patient’s gender.
In the 2–6 weeks before symptom onset how many
male sex partners did the patient have? ...........................................................................................................................................
female sex partners did the patient have? ........................................................................................................................................
In the 2–6 weeks before symptom onset
0
1
2–5
❑
❑
❑
❑
❑
❑
>5 Unk
❑
❑
❑
❑
Yes
No
Unk
Did the patient inject drugs not prescribed by a doctor? .................................................................................................................
❑
❑
❑
Did the patient use street drugs but not inject? ...............................................................................................................................
❑
❑
❑
Did the patient travel or live outside of the U.S.A. or Canada? .......................................................................................................
❑
❑
❑
❑
❑
❑
❑
❑
❑
Foodborne — associated with an infected food handler .............................................................................................................
❑
❑
❑
Foodborne — NOT associated with an infected food handler ....................................................................................................
❑
❑
❑
❑
❑
❑
If yes, where?
1) ___________________________ 2) ______________________________
(Country)
3) ___________________________
What was the principle reason for travel?
❑ Business
❑ New Immigrant
❑ Other
❑ Tourism
❑ Visiting relatives/friends
❑ Adoption
❑ Unknown
In the 3 months prior to symptom onset did anyone in the patient’s household travel outside of the U.S.A. or Canada? ................
If yes, where?
1) ___________________________ 2) ______________________________
(Country)
3) ___________________________
Is the patient suspected as being part of a common-source outbreak? ................................................................................................
If yes, was the outbreak
Specify food item ________________________________
Waterborne.................................................................................................................................................................................
Source not identified...................................................................................................................................................................
❑
❑
❑
Was the patient employed as a food handler during the TWO WEEKS prior to onset of symptoms or while ill? ...............................
❑
❑
❑
VACCINATION HISTORY
Yes
• Has the patient ever received the hepatitis A vaccine? .........
If yes, how many doses? ....................................................
• Has the patient ever received immune globulin? ..................
No
Unk
❑
❑
❑
1
>2
Y __
Y __
Y __
Y (year)
• In what year was the last dose received? ............. __
❑
❑
Yes
No
Unk
❑
❑
❑
M __
M / __
Y __
Y __
Y __
Y (mo/year)
• If yes, when was the last dose received?.............. __
2
Patient History — Acute Hepatitis B
Case ID: _______________________________________________
Yes
No
Unk
❑
❑
❑
Sexual .....................................................................
❑
❑
Household (non-sexual)..........................................
❑
❑
During the 6 weeks – 6 months prior to onset of
symptoms was the patient a contact of a person with
confirmed or suspected acute or chronic hepatitis B virus
infection?
What is the sexual preference of the patient?
❑ Homosexual
❑ Heterosexual
❑ Bisexual
❑ Unknown
Ask both of the following questions regardless of the
patient’s gender.
In the 6 months before symptom onset, how many
0
1
2–5
❑
• male sex partners did the patient have? .................
❑
❑
❑
❑
❑
❑
• female sex partners did the patient have? ..............
❑
❑
❑
❑
❑
If yes, type of contact
Other: __________________________
During the 6 weeks – 6 months prior to onset of symptoms
>5 Unk
Was the patient EVER treated for a sexuallytransmitted disease? ....................................................
• If yes, in what year was the most recent
Y __
Y __
Y __
Y
treatment? __
Yes
❑
No
❑
Unk
❑
During the 6 weeks – 6 months prior to onset of
symptoms
Yes
No
Unk
Yes
No
Unk
❑
❑
❑
or other object contaminated with blood? ................
❑
❑
❑
• inject drugs not prescribed by a doctor? ...............
❑
❑
❑
• receive blood or blood products [transfusion] ..........
❑
❑
❑
• use street drugs but not inject? ..............................
• Did the patient have any part of their body
pierced (other than ear)? ......................................
Where was the piercing performed? (select all
that apply)
❑ commercial parlor/shop
❑ correctional facility ❑ other ____________
❑
❑
❑
❑
❑
❑
• Did the patient have dental work or oral surgery?
• Did the patient have surgery ? (other than oral
surgery) ................................................................
❑
❑
❑
❑
❑
❑
Did the patient:
• undergo hemodialysis? .............................................
• have an accidental stick or puncture with a needle
M __
M / __
D __
D / __
Y __
Y __
Y __
Y
If yes, when? __
• receive any IV infusions and/or injections in the
outpatient setting .....................................................
❑
❑
❑
• have other exposure to someone else’s blood ............
❑
❑
❑
specify: __________________________________
During the 6 weeks – 6 months prior to onset of
symptoms
• Was the patient employed in a medical or dental
field involving direct contact with human blood? .....
❑
❑
Was the patient: (check all that apply)
❑
If yes, frequency of direct blood contact?
• hospitalized? ....................................................
❑
❑
❑
❑ Frequent (several times weekly) ❑ Infrequent
• a resident of a long term care facility? .............
❑
❑
❑
• incarcerated for longer than 24 hours ..............
if yes, what type of facility (check all that
apply)
❑
❑
❑
• Was the patient employed as a public safety worker
(fire fighter, law enforcement or correctional officer)
having direct contact with human blood? .................
❑
❑
❑
If yes, frequency of direct blood contact?
prison ........................................................
❑
❑
❑
❑ Frequent (several times weekly) ❑ Infrequent
jail .............................................................
❑
❑
❑
juvenile facility ..........................................
❑
❑
❑
Yes
No
Unk
❑
❑
❑
Did patient have a negative HBsAg test within 6
months prior to positive test? ......................................
M __
M // __
D __
D // __
Y __
Y __
Y __
Y
Verified test date: __
❑
❑
❑
Was the patient tested for hepatitis D? ........................
❑
❑
❑
Did patient have a co-infection with hepatitis D? ........
❑
❑
❑
• Did the patient receive a tattoo? ...............................
Where was the tattooing performed? (select all
that apply)
❑
❑
❑
❑ commercial parlor/shop
During his/her lifetime, was the patient EVER
❑ correctional facility ❑ other ______________
incarcerated for longer than 6 months? .......................
• If yes,
Yes
No
Unk
Did the patient ever receive hepatitis B vaccine? ................
❑
❑
❑
what year was the most recent
Y __
Y __
Y __
Y
incarceration? __
1
❑
2
❑
3+
❑
M __
MM
for how long? __
__ (mos)
If yes, how many shots? ...............................................
• In what year was the last shot received? __ __ __ __
Was the patient tested for antibody to HBsAg (anti-HBs)
within 1-2 months after the last dose ................................
• If yes, was the serum anti-HBs ≥ 10mIU/ml? ............
Yes
❑
No
❑
Unk
❑
❑
❑
❑
(answer ‘yes’ if the laboratory result was reported as
‘positive’ or ‘reactive’)
3
Perinatal Hepatitis B Virus Infection
Case ID: _______________________________________________
ETHNICITY OF MOTHER:
RACE OF MOTHER:
❑ Amer Ind or Alaska Native
❑ Black or African American
❑ Asian
❑ Native Hawaiian or Pacific Islander
❑ White
❑ Unknown
Non-hispanic ....................... ❑
Other/Unknown................... ❑
❑ Other Race, specify: ____________________________
Yes
No
Unk
Was Mother born outside of United States?..................................................
❑
❑
❑
Was the Mother confirmed HBsAg positive prior to or at time of delivery? ..
❑
❑
❑
• If no, was the mother confirmed HBsAg positive after delivery? ............
❑
❑
❑
Date of earliest HBsAg positive test result ....................................................
How many doses of hepatitis B vaccine did the child receive ? ......................
M __
M / __
D __
D / __
Y __
Y __
Y __
Y
__
0
1
2
3+
❑
❑
❑
❑
• When?
D __
D / __
Y __
Y Y
• Dose 1 M
__ M
__ / __
__ Y
__
D __
D / __
Y __
Y Y
• Dose 2 M
__ M
__ / __
__ Y
__
D __
D / __
Y __
Y Y
• Dose 3 M
__ M
__ / __
__ Y
__
Did the child receive hepatitis B immune globulin (HBIG)? .........................
• If yes, on what date did the child receive HBIG? ....................................
Hispanic............................... ❑
Yes
No
Unk
❑
❑
❑
M __
M / __
D __
D / __
Y __
Y __
Y __
Y
__
4
If yes, what country? ____________________________
Patient History — Acute Hepatitis C
Case ID: _______________________________________________
During the 2 weeks – 6 months prior to onset of symptoms
was the patient a contact of a person with confirmed or
suspected acute or chronic hepatitis C virus infection? ........
Yes
No
Unk
❑
❑
❑
❑
❑
❑
What is the sexual preference of the patient?
❑ Heterosexual
❑ Homosexual
❑ Bisexual
❑ Unknown
Ask both of the following questions regardless of
the patient’s gender.
In the 6 months before symptom onset, how many
If yes, type of contact
Sexual .........................................................................
Household (non-sexual)..............................................
❑
❑
❑
• male sex partners did the patient have? ...............
Other: __________________________
❑
❑
❑
• female sex partners did the patient have? ............
Yes
No
Unk
❑
❑
❑
❑
❑
❑
❑
❑
❑
• undergo hemodialysis? ..................................................
• have an accidental stick or puncture with a needle or
other object contaminated with blood? .........................
• receive blood or blood products [transfusion] ...............
If yes, when?
• receive any IV infusions and/or injections in the
outpatient setting ..........................................................
• have other exposure to someone else’s blood ................
specify: ______________________________
During the 2 weeks – 6 months prior to onset of symptoms
• Was the patient employed in a medical or dental field
involving direct contact with human blood ? ................
If yes, frequency of direct blood contact?
❑ Frequent (several times weekly) ❑ Infrequent
• Was the patient employed as a public safety worker
(fire fighter, law enforcement or correctional officer)
having direct contact with human blood? ......................
If yes, frequency of direct blood contact?
❑ Frequent (several times weekly) ❑ Infrequent
• Did the patient receive a tattoo? ...................................
Where was the tattooing performed? (select all that
apply)
❑ commercial parlor/shop
❑ correctional facility ❑ other ______________
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
2–5
❑
>5 Unk
❑
❑
❑
❑
❑
❑
❑
No
❑
Unk
• inject drugs not prescribed by a doctor? .............
❑
❑
❑
• use street drugs but not inject? ............................
❑
❑
❑
Did the patient have a negative HCV antibody test
within 6 months to a positive test? ............................
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
❑
• hospitalized? .......................................................
❑
❑
❑
• a resident of a long term care facility? ................
❑
❑
❑
• incarcerated for longer than 24 hours .................
If yes, what type of facility (check all that
apply)
❑
❑
❑
prison .........................................................
❑
❑
❑
❑
During the 2 weeks – 6 months prior to onset of
symptoms
❑
❑
❑
1
❑
Yes
❑
Was the patient EVER treated for a sexuallytransmitted disease? ..................................................
• If yes, in what year was the most recent
Y __
Y __
Y __
Y
treatment? __
During the 2 weeks – 6 months prior to onset of symptoms
Did the patient:
0
❑
M __
M / __
D __
D / __
Y __
Y __
Y __
Y
Vertified test date __
During the 2 weeks – 6 months prior to onset of
symptoms
• Did the patient have any part of their body
pierced (other than ear)? .....................................
Where was the piercing performed? (select all
that apply)
¨ commercial parlor/shop
¨ correctional facility
¨ other ______________
• Did the patient have dental work or oral
surgery? ..............................................................
• Did the patient have surgery ? (other than oral
surgery) ...............................................................
❑
Was the patient – (check all that apply)
jail ..............................................................
❑
❑
❑
juvenile facility ...........................................
❑
❑
❑
Yes
No
Unk
❑
❑
❑
❑
❑
❑
During his/her lifetime, was the patient EVER
incarcerated for longer than 6 months? .....................
• If yes,
what year was the most recent
Y __
Y __
Y __
Y
incarceration? __
M __
M __
M (mos)
for how long? __
Has the patient recieved medication for the type of
hepatitis being reported? ...........................................
5
Patient History — Chronic Hepatitis B Infection
Case ID: _______________________________________________
The following questions are provided as a guide for the investigation of lifetime risk factors for HBV infection. Routine collection of risk factor information for
persons who test HBV positive is not required. However, collection of risk factor information for such persons may provide useful information for the development
and evaluation of programs to identify and counsel HBV-infected persons.
Yes
Did the patient receive clotting factor concentrates
produced prior to 1987? ...................................................
No
Unk
❑
❑
❑
Was the patient ever employed in a medical or dental field
involving direct contact with human blood?........................
Was the patient ever on long-term hemodialysis? .............
Has the patient ever injected drugs not prescribed by a
doctor even if only once or a few times?...........................
How many sex partners has the patient had (approximate
lifetime)? ___________
❑
❑
❑
What is the birth country of the mother ?
❑
❑
❑
_______________________________________
Has the patient recieved medication for the type of
hepatitis being reported? .....................................................
Was the patient ever incarcerated?....................................
Was the patient ever treated for a sexually transmitted
disease? ............................................................................
Was the patient ever a contact of a person who had
hepatitis? ..........................................................................
❑
❑
❑
❑
❑
❑
❑
❑
❑
• Sexual ....................................................................
❑
❑
❑
• Household [Non-sexual] ........................................
❑
❑
❑
• Other .....................................................................
❑
❑
❑
If yes, type of contact
6
Yes
No
Unk
❑
❑
❑
❑
❑
❑
Patient History — Hepatitis C Infection (past or present)
Case ID: _______________________________________________
The following questions are provided as a guide for the investigation of lifetime risk factors for HCV infection. Routine collection of risk factor information for
persons who test HCV positive is not required. However, collection of risk factor information for such persons may provide useful information for the development
and evaluation of programs to identify and counsel HCV-infected persons.
Yes
No
Unk
Did the patient receive a blood transfusion prior to 1992? .....
❑
❑
❑
Did the patient receive an organ transplant prior to 1992? .....
Did the patient receive clotting factor concentrates produced
prior to 1987? .........................................................................
❑
❑
❑
❑
❑
❑
Was the patient ever on long-term hemodialysis? ...................
Has the patient ever injected drugs not prescribed by a
doctor even if only once or a few times?.................................
How many sex partners has the patient had (approximate
lifetime)? ___________
❑
❑
❑
❑
❑
❑
Was the patient ever incarcerated?..........................................
Was the patient ever treated for a sexually transmitted
disease? ..................................................................................
❑
❑
❑
❑
❑
❑
Was the patient ever a contact of a person who had hepatitis?
❑
❑
❑
• Sexual ..........................................................................
❑
❑
❑
• Household [Non-sexual] ..............................................
❑
❑
❑
• Other ...........................................................................
❑
❑
❑
Was the patient ever employed in a medical or dental
field involving direct contact with human blood? ...........
Has the patient recieved medication for the type of
hepatitis being reported? ................................................
If yes, type of contact
7
Yes
No
Unk
❑
❑
❑
❑
❑
❑
| File Type | application/pdf |
| File Title | VIRAL HEPATITIS CASE REPORT |
| Author | HHS | CDC | OID | NCHHSTP | DVH |
| File Modified | 2019-02-21 |
| File Created | 2013-05-08 |