Disease or Condition-Specific Information (Please complete if appropriate)

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1 Arkansas Department of Health 4815 West Markham Street, Communicable Disease Reporting Form Slot #32 Fax Reports to (501) Little Rock, AR Please Print Legibly Reporting facility: Address: City: State: Zip Code: Phone: ( ) - Reporter name: Reporter phone: ( ) - Physician Last name: First: phone: ( ) - Disease or Condition: Date of onset: / / Patient Last name: First: Date of birth: / / Address: Phone: ( ) - City: State: Zip: County: Gender: Male Female Ethnicity: Hispanic Not Hispanic Race: American Indian/Alaskan Asian Black Hawaiian/Pac Islander White Other Method of diagnosis: clinical laboratory Specific name of test: Specimen (blood, CSF, sputum, stool, etc.): Date lab specimen collected: / / Food handler: Yes No Unknown Child/worker in a daycare: Yes No Healthcare worker: Yes No Unknown Pregnant: Yes No Due Date: / / Nursing Home: Yes No Unknown Jail: Yes No Was the patient hospitalized Yes No Unknown Admission date: / / Reason seen: Discharge date: / / Died: Yes No Unknown Other Lab Results, Treatments or Additional Comments: (Please include test name, source, result and dates) Disease or Condition-Specific Information (Please complete if appropriate) If Hepatitis: Hep A IgM antibody: Positive Negative Not Done LFT collection date: / / Hep B IgM antibody: Positive Negative Not Done Total bilirubin: Hep B surface antigen: Positive Negative Not Done SGOT (AST): Hep C antibody: Positive Negative Not Done SGPT (ALT): (Signal to cut off ratio: ) Was patient jaundiced Yes No Does patient have previous diagnosis of Hepatitis Yes No Was patient symptomatic Yes No If Tickborne Disease: Diagnostic Tests: IgG titer: IgM titer: PCR: Symptoms: Fever Rash Myalgia Headache Anemia Leukopenia Thrombocytopenia Elevated hepatic transaminases Other If Influenza: Test Performed: Rapid antigen: PCR result: Other: Vaccinated this season Yes No Unknown If yes, Date: / / Revised 9/1/2015

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