Case Report # ________________ Smallpox Case Investigation Supplementary

Case Report # ________________

Smallpox Case Investigation Supplementary (Form 1B)

STATE

Patient Information

1. DATE OF FOLLOW-UP:
Month

Day

Year

2. NAME OF PERSON FILING THIS CASE:
Last: __________________________ ___ ___First: _________________________________ Middle Initial: ____
3. PATIENTS NAME:
Last: ________________________________ First: _________________________________ Middle Name: _________________________ Suffix: _________ Nickname: _________________

Yes

4. ADMITTED TO 2ND HOSPITAL OR ISOLATION SITE?

No

Unknown

IF YES, DATE OF ADMISSION:
Month

HOSPITAL NAME:

Day

Year

2nd HOSPITAL MEDICAL RECORD #: ________________________
City

State

Clinical Course
5. SMALLPOX TYPES*: RASH (MOST SEVERE STAGE):

Ordinary Type:

Confluent Face and other site

Semi-confluent Face only

Discrete lesions

Modified Type
Flat Type
Hemorrhagic Type:

Early

Late

*Ordinary type:
Confluent
Semi-confluent
Discrete

Raised, pustular lesions with 3 sub-types:
Confluent rash on face and forearms
Confluent rash on face, discrete elsewhere
Areas of normal skin between pustules, even on face

Modified type:

Like ordinary type but with an accelerated course

Flat type:
Hemorrhagic type:
Early
Late

Pustules remain flat; usually confluent or semi-confluent, usually fatal
Widespread hemorrhages in skin and mucous membranes
With purpuric rash, always fatal
With hemorrhage into base pustules, usually fatal

6. DATE LAST SCAB FELL OFF:
Month

Day

Year

7. COMPLICATIONS (Check all that apply).

Skin Secondary bacterial infection:
Yes
No
Unknown
Ocular corneal ulcer or keratitis:
Yes
No
Unknown
CNS encephalitis:
Yes
No
Unknown
Respiratory: Bronchitis
Yes
No
Unknown
Respiratory: Pneumonia
Yes
No
Unknown
Joint/Bones: Arthralgia
Yes
No
Unknown
Joint/Bones: Osteitis
Yes
No
Unknown
Hemorrhagic:
Yes
No
Unknown
Shock:
Yes
No
Unknown
Other, please specify: ____________________________________________________
Yes

8. ANTIVIRAL MEDICATION: CIDOFOVIR

No

Unknown

OTHER ANTIVIRAL MEDICATIONS, SPECIFY: ______________________________________________________________________________________
9. SMALLPOX VACCINATION HISTORY
WAS THE CASE VACCINATED SINCE THE COMPLETION OF FORM 1A?
DATE:
Month

Day

Yes

No

Unknown

VACCINE TAKE RECORDED AT 7 DAYS? Yes

No

Unknown

Year

Clinical Course Disposition
10. DATE OF HOSPITAL DISCHARGE:
Month
COMPLICATIONS AT DISCHARGE:

Yes

Day

Year

No

Unknown

IF YES, PLEASE SPECIFY: _____________________________________________________________________________________________________

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Draft Version 4.1 31 Dec 01

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