PATIENT INFORMATION

Last name_____________________ First Name __________________ MI __ County/Borough_______________

Address ____________________________________City _____________________ Zipcode________State____

Telephone -H (____)_____-_______ W (____)_____-_______ Date of Birth____/____/____ Age______

Occupation:______________________

Race: White Black Am Indian/Alaskan Asian Other

Ethnicity: Hispanic Non-hispanic Unk Sex: Male Female

Pregnant: Yes No Unknown

CLINICAL INFORMATION

Hospitalized? Yes No

If yes, Hospital Name__________________________________________________

Street Address____________________________ City____________________ State_____ Zip __________

Medical record # ________________Date of admission ____/____/____ Date of discharge/transfer ____/____/___

Date of first symptoms ____/____/____ Date of first neurologic symptoms ____/____/____

Current Diagnosis: encephalitis meningitis other________________________

Fever (> 38C or 100F)	Yes	No	Unknown
Altered mental status	Yes	No	Unknown
Headache	Yes	No	Unknown
Stiff neck/Meningeal signs	Yes	No	Unknown
Seizures	Yes	No	Unknown
Muscle weakness	Yes	No	Unknown
Rash	Yes	No	Unknown
Muscle pain	Yes	No	Unknown
Other neurologic signs	Yes	No	Unknown
Joint pain	Yes	No	Unknown

Other symptoms (current or 1 month before onset)__________________________________________________

Outcome Recovered Died Unknown If patient died, date of death ____/____/____

LABORATORY INFORMATION / TEST RESULTS

CSF (specify units) Date ____/____/____ Abnormal? Yes No Unknown

Glu ________ Prot ________ RBC _______ WBC ________ Diff: Segs% _____ Lymphs%_____

Gram stain ________________ Bacterial Culture ____________ Fungal / Parasitic tests _____________

Viral test results (Culture/ Serology / PCR) _________________________________________________

CBC (specify units) Date ____/____/____ WBC ________ Diff: Segs% ________ Lymphs% ________

MRI Date	____/____/____	Result____________________________________________________________
CT Date	____/____/____	Result____________________________________________________________
EMG Date	____/____/____	Result____________________________________________________________

ANTIVIRALTREATMENT Yes No Unk If yes, list below.	Date started:
1. ___________________________________________________________________	____________
2.____________________________________________________________________	____________

RISK FACTOR INFORMATION (during 1 month before onset)				Location	Dates
Travel outside country?	Yes	No	Unk	___________________	______________
Travel outside New York State?	Yes	No	Unk	___________________	______________
Travel outside county of residence?	Yes	No	Unk	___________________	______________
				___________________	______________
Animal or arthropod contact?	Yes	No	Unk Specify:	___________________________________

REPORTED BY:

Last name ____________________First name _________________Title (ICN, Resident, Attending) ____________ Work address________________________ City ___________________________ State___ Zip Code __________

Telephone (____)_____-_______ Pager (____)_____-______

Date of Report: ___/___/___

This form must be faxed to the Local Health Unit and a copy submitted with the laboratory specimen(s) to the NYSDOH Wadsworth Center Laboratory.

Date of Submission: ___/___/___ Initial** Repeat Specimen

IDENTIFYING PATIENT INFORMATION

Last name ___________________________________ First name ___________________________MI _____

Date of Birth____/____/____ Age______ County / Borough _______________________________________

Street Address: ____________________________________________________________________________

City: _______________________________________________________ State____ Zipcode ____________

If hospitalized, Hospital name_____________________________ Medical record # _________________

Street Address: _______________________________________________________________________

City _________________________________________ State __________ Zip Code ________________

Date of first symptom: ____/____/____

REQUESTING PHYSICIAN

Last name ___________________________________First name ______________________________________

Work address________________________________________________________________________________

City _________________________________________________ State___________ Zip Code _______________

Telephone (____)_____-_______ Pager (____)_____-______

To submit specimens for encephalitis testing:

1. The local health department must be contacted prior to specimen submission.

2. This form** must be faxed to the local health department AND submitted along with the clinical specimens.

Send Specimens to: Dr. Cinnia Huang Griffin Laboratory New York State Department of Health Route 155 Guilderland, NY 12084

**If this is an initial specimen submission, the Encephalitis/ Meningitis Initial Case Report Form must also be completed.

Send questions or comments to: westnile@health.state.ny.us
Revised: May 2000

What'sThis Month / HELP! / Search our Web Site