Contact number: Information collected from: PATIENT COURSE POST COMPLETED YES NO DATE FORM WITH __/__/____ __/__/____ date: Patient hospitalised? (If admitted) SPECIMEN TO: If female, pregnant? NO Hospital name: (If admitted) Special Viral (If Pathogens Lab, __/__/____ discharged) National Institute __/__/____ Patient is (If deceased) for Treatment(s) Communicable Diseases, National Health Laboratory Service, 1 AND PATHOLOGICAL (Tick appropriate box (yes; no; UNK: unknown) Modderfontein Road, __/__/____ __/__/____ Sandringham Signs - Pathology tests 2192, South NO YES NO YES NO UNK Complications Africa Reduced Malaria negative consciousness FAX OR Jaundice - Yellow eyes Platelets<100,000 EMAIL COMPLETED Hepatomegalomy unit date FORM TO: Renal failure Lowest Plts. count: 10^9/L 0865964423 or cezd@nicd.ac.za Arrhythmia Lowest WBC 10^9/L count: Rash (If yes, describe) Lowest serum g/L ALB: Lowest BP: Petechiae Highest C-RP: mg/L /Purpura/ecchymosis Overt bleeding Highest AST: U/L (If yes, describe from where): Highest ALT: U/L AST/ALT: 10^9/L Seizures Total Bilirubin: mg/dL and EXPOSURE HISTORY YES NO UNK a history of travel outside South Africa? prior to onset? __/__/____ __/__/____ Travelled (country) (where within to: country) Holiday Visiting relative business Other, state: any bites? __/__/____ If yes, give date: bites Animal bites No bites Unknown RECORD vaccination? (If vaccinated, specify countries and (Tick appropriate box) to travel to yellow fever declared country Countries: to travel to yellow fever declared country
Contact number: Information collected from: PATIENT COURSE YES NO DATE date: __/__/____ Patient hospitalised? __/__/____ (If admitted) If female, pregnant? NO Hospital name: (If admitted) __/__/____ (If discharged) Patient is __/__/____ (If deceased) Treatment(s) AND PATHOLOGICAL (Tick appropriate box (yes; no; UNK: unknown) __/__/____ __/__/____ NO Signs - Complications YES NO Pathology tests YES NO UNK Reduced consciousness Malaria negative Jaundice - Yellow eyes Platelets<100,000 Hepatomegalomy unit date Renal failure Lowest Plts. count: 10^9/L Arrhythmia Lowest WBC count: 10^9/L Rash (If yes, describe) Lowest serum ALB: g/L Lowest BP: Petechiae /Purpura/ecchymosis Highest C-RP: mg/L Overt bleeding Highest AST: U/L (If yes, describe from where): Highest ALT: U/L AST/ALT: 10^9/L Seizures Total Bilirubin: mg/dL and EXPOSURE HISTORY YES NO UNK a history of travel outside South Africa? prior to onset? __/__/____ __/__/____ Travelled (country) to: (where within country) Holiday Visiting relative business Other, state: any bites? bites Animal bites No bites Unknown If yes, give date: __/__/____ RECORD vaccination? (Tick appropriate box) (If vaccinated, specify countries and to travel to yellow fever declared country Countries: to travel to yellow fever declared country POST COMPLETED FORM WITH SPECIMEN TO: Special Viral Pathogens Lab, National Institute for Communicable Diseases, National Health Laboratory Service, 1 Modderfontein Road, Sandringham 2192, South Africa FAX OR EMAIL COMPLETED FORM TO: 0865964423 or cezd@nicd.ac.za
CIFSVPL_Yellowfever(1).docx