LISTERIA INVESTIGATION FORM This form should be completed in full for each laboratory-confirmed listeria case INTERVIEWER DETAILS Name Surname Contact Date investigation initiated dd/mm/yyyy number Date investigation completed dd/mm/yyyy LABORATORY INFORMATION Laboratory name Laboratory specimen no. ⎕ ⎕ ⎕ Specimen type Blood CSF Other Specify other SOURCE(S) OF INFORMATION ⎕ ⎕ ⎕ ⎕ Interview Yes No Medical record review Yes No ⎕ ⎕ ⎕ ⎕ Person(s) Relative Parent Caregiver Guardian Patient⎕ interviewed Telephonic Yes ⎕ No ⎕ Telephone number interview DEMOGRAPHIC DETAILS Name Surname Date of birth dd/mm/yyyy Age Age D M Y Age Gender Contact number units unknown⎕ (M/F/U) Race Coloured⎕ Indian⎕ White⎕ Other⎕ Specify other Home address Code District Province Place of employment on ⎕ Identity number Unknown ⎕ ⎕ ⎕ Has patient lived in South Africa for the last Yes No Unknown State country month? CLINICAL DETAILS If symptomatic date of onset of symptoms (Y/N/U) If symptomatic, tick all the listed symptoms below that the person experienced: Fever ⎕ Confusion ⎕ Headaches ⎕ Abdominal cramps ⎕ Flu-like illness ⎕ Muscle aches Convulsions Loss of balance⎕ Neck-stiffness ⎕ Diarrhoea/vomiting ⎕ ⎕ ⎕ Other ⎕ Specify other Unknown ⎕ Blood pressure Unknown ⎕ Mechanical Yes ⎕ No ⎕ Unknown ⎕ Cardiac arrest Yes ⎕ No ⎕ Unknown ⎕ ventilation ⎕ ⎕ GCS /15 Unknown Mental status Unknown ⎕ ⎕ ⎕ Patient diagnosis Bacteraemia/Sepsis Meningitis Pneumonia Granulomatosis Other ⎕ Specify other infantiseptica ⎕ HOST RISK FACTORS Alcohol dependency Chronic liver disease ⎕ Chronic renal disease (incl. Fanconi’s anaemia) ⎕ ⎕ ⎕ ⎕ ⎕ Pregnancy Malignancy Metabolic diseases (incl. diabetes mellitus) ⎕ ⎕ Prematurity: age at Advanced age (≥65 years) Immunosuppression treatment (steroids/chemo) birth⎕ List any other
LISTERIA INVESTIGATION FORM This form should be completed in full for each laboratory-confirmed listeria case INTERVIEWER DETAILS Name Surname Contact number Date investigation initiated dd/mm/yyyy Date investigation completed dd/mm/yyyy LABORATORY INFORMATION Laboratory name Laboratory specimen no. Specimen type Blood ⎕ CSF ⎕ Other ⎕ Specify other SOURCE(S) OF INFORMATION Interview Yes ⎕ No ⎕ Medical record review Yes ⎕ No ⎕ Person(s) interviewed Relative ⎕ Parent ⎕ Caregiver ⎕ Guardian ⎕ Patient⎕ Telephonic interview Yes ⎕ No ⎕ Telephone number DEMOGRAPHIC DETAILS Name Surname Date of birth dd/mm/yyyy Age Age units D M Y Age unknown⎕ Gender (M/F/U) Contact number Race Coloured⎕ Indian⎕ White⎕ Other⎕ Specify other Home address Code District Province Place of employment Identity number Unknown ⎕ Has patient lived in South Africa for the last month? Yes ⎕ No ⎕ Unknown ⎕ State country CLINICAL DETAILS (Y/N/U) If symptomatic date of onset of symptoms If symptomatic, tick all the listed symptoms below that the person experienced: Fever ⎕ Confusion ⎕ Headaches ⎕ Abdominal cramps ⎕ Flu-like illness ⎕ Muscle aches ⎕ Convulsions ⎕ Loss of balance⎕ Neck-stiffness ⎕ Diarrhoea/vomiting ⎕ Other ⎕ Specify other Unknown ⎕ Blood pressure Unknown ⎕ Mechanical ventilation Yes ⎕ No ⎕ Unknown ⎕ Cardiac arrest Yes ⎕ No ⎕ Unknown ⎕ GCS /15 Unknown ⎕ Mental status Unknown ⎕ Patient diagnosis Bacteraemia/Sepsis ⎕ Meningitis ⎕ Pneumonia ⎕ Granulomatosis infantiseptica ⎕ Other ⎕ Specify other HOST RISK FACTORS Alcohol dependency ⎕ Chronic liver disease ⎕ Chronic renal disease (incl. Fanconi’s anaemia) ⎕ Pregnancy ⎕ Malignancy ⎕ Metabolic diseases (incl. diabetes mellitus) ⎕ Prematurity: age at birth⎕ Advanced age (≥65 years) ⎕ Immunosuppression treatment (steroids/chemo) ⎕ List any other on