Special Viral Pathogens Laboratory: +2711 386 6336 (or +2782 903 9131)
NICD Hotline for Clinical Advice: +2782 883 9920
SUSPECTED YELLOW FEVER CASE HISTORY FORM
Filled in by:
Date:
__/__/____
PATIENT INFORMATION
Name:
Age:
Years
Sex:
M
Contact number:
Information collected from:
F
PATIENT COURSE
YES
Birth date:
__/__/____
If female, pregnant?
YES
NO
NO
Hospital name:
Date(s) of onset:
Symptoms
°C
Fever
Chills
Headache
Malaise
Nausea
Vomiting
Diarrhoea
Abdominal
pain
Muscle pain
Joint pain
Back pain
Neckstiffness
YES
__/__/____
__/__/____
Patient is alive?
Treatment(s) given?
Referring physician:
Number for physician:
__/__/____
NO
UNK
(If admitted)
(If admitted)
Address:
CLINICAL FEATURES AND PATHOLOGICAL FINDINGS
DATE
__/__/____
Patient hospitalised?
(If discharged)
(If deceased)
(Tick appropriate box (yes; no; UNK: unknown)
__/__/____
Signs - Complications
Reduced consciousness
Jaundice - Yellow eyes
Hepatomegalomy
Renal failure
Arrhythmia
Rash (If yes, describe)
YES
NO
UNK
Pathology tests
Malaria negative
Platelets<100,000
YES
NO
UNK
count
unit
10^9/L
10^9/L
g/L
mmHG
date
__/__/____
__/__/____
__/__/____
__/__/____
Highest C-RP:
mg/L
__/__/____
Highest AST:
Highest ALT:
AST/ALT:
Total Bilirubin:
U/L
U/L
10^9/L
mg/dL
__/__/____
__/__/____
__/__/____
__/__/____
Lowest Plts. count:
Lowest WBC count:
Lowest serum ALB:
Lowest BP:
Petechiae
/Purpura/ecchymosis
Overt bleeding
(If yes, describe from where):
Seizures
Other Findings:
PATIENT TRAVEL and EXPOSURE HISTORY
YES
Does the patient have a history of travel outside South Africa?
If yes, Within 30 days prior to onset?
Date(s) From:
__/__/____ Until: __/__/____
Travel purpose:
Holiday
Has the patient received any bites?
Mosquito bites
Tick bites
If yes, give details:
Animal bites
Visiting relative
No bites
NO
UNK
Travelled
to:
business
Unknown
(country)
(where within country)
Other, state:
If yes, give date:
PATIENT VACCINATION RECORD
Did patient receive yellow fever vaccination? (Tick appropriate box)
≥ 30 days prior to travel to yellow fever declared country
≥ 10 days prior to travel to yellow fever declared country
< 10 days prior to travel to yellow fever declared country
Never travelled to yellow fever declared country
Never received vaccination but travelled in past to yellow fever declared country
Unknown
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
__/__/____
(If vaccinated, specify countries and dates)
Countries:
Date(s):
Last vaccinated
__/__/____
__/__/____
FAX OR EMAIL COMPLETED FORM TO:
0865964423 or cezd@nicd.ac.za