Pandemic(H1N1)2009CaseHistoryForm(ICUandFatal.docVIP

Pandemic H1N1 2009 Case History Form ICU and Fatal Cases Case definition: 1 a clinical syndrome consistent with influenza or its complications; and 2 either probable or confirmed pandemic H1N1 by laboratory testing; and 3 been either hospitalized in an ICU OR expired at any location e.g. hospital, ER, home, etc LHD ____________________________ CDPH Case ID: CA_____________ Date reported to LHD _____/_____/_____ Last name ______________________ First name DOB ____/_____/____ Sex: ? Female ? Male Street Address: ________________________ __________ City ______________________ Zip Code _______________ Race: ? White ? Black ? Native American ? Asian/PI ? Other ? Unknown Ethnicity: ? Hispanic ? Non-Hispanic Case Status: ? Probable Pandemic H1N1 ? Confirmed Pandemic H1N1 ? A-PCR positive subtype unknown ? A H3 ? A H1 ? A-PCR unconfirmed e.g. rapid test, culture or DFA positive only ? B Date onset of symptom s : ______/______/______ Level of medical care check all that apply : ? Clinic ? ER ? Inpatient Ward ? ICU ? None If hospitalized, Date of admission: _____/_____/_____ Date of discharge: _____/_____/_____ Weight ________ Height ________ BMI:_________ Recent travel? ?Yes ? No If yes, where: ________________ Recent ill contacts: ?Yes ?No If yes, who: _____________ Occupation: ________________________________________ Symptoms that occurred during the current illness: ? Fever 38o ? Cough ? Sore throat ? Rhinorrea ? Chills ? Nausea/vomiting ? Diarrhea ? Muscle aches ? Shortness of breath ? Altered mental status ? Seizures ? Other; specify______________________________________ Complications that occurred during the acute illness: ? Pneumonia/ARDS ? Bronchiolitis ? 2? bacterial pneumonia ? Encephalitis/encephalopathy ? Myocarditis ? Sepsis/Multi-organ Failure ? Other, specify __________________________________ Significant Past Medical History check all that apply Cardiac disease ? Yes ? No ? Unk Chro