ARBOVIRUS Laboratory: +2711 386 6424/6391 (or +2782 903 9131)
NICD Hotline for Clinical Advice: +2782 883 9920
SUSPECTED ARBOVIRUS CASE INVESTIGATION FORM
Filled in by:
Date:
Contact number:
Information collected from:
__/__/____
DISEASE(S) UNDER INVESTIGATION
(Tick appropriate boxes)
Sindbis
Chikungunya
West Nile
Dengue
Rift Valley
Other suspected clinical diagnoses:
PATIENT INFORMATION
Name:
Age:
Years
Sex:
M
F
Address:
Other arbovirus:
PATIENT COURSE
YES
Birth date:
__/__/____
Patient hospitalised?
Hospital name:
Severity of illness?
Treatment(s) given?
Referring physician:
Number for physician:
NO
DATE
__/__/____
(If admitted)
Mild
__/__/____ (If discharged)
Moderate
Acute/Severe
Consultation date:
__/__/____
Px responsive to treatment?
Not
CLINICAL FEATURES
Date of onset:
__/__/____
And/or
Duration illness:
Main Syndrome:
(Tick appropriate box)
Fever without rash
Fever with rash
Arthritis and Rash
Encephalitis/meningitis
Retinitis/conjunctivitis
Other remarkable symptoms:
If present,
Describe:
Fever:
Max Temp
Rash (Site)
face
arm
palms
trunk
legs
soles
Encephalitis
Hemorrhage
headache
epitaxis
°C
neck stiffness
haematemesis
biphasic
vomiting
melaena
constant
confusion
menorrhagia
Duration (days):
seizures
petechiae
unconscious
purpura
coma
from venepuncture
PATHOLOGICAL FINDINGS (Tick appropriate box (yes, no; UNK: unknown); Attach test results)
YES NO
UNK
YES NO
UNK Additional findings:
Malaria negative
Leucopenia
Thrombocytopenia
Lowest WBC count:
109/L
Lowest plts count:
109/L Elevated liver function
Latest plts. Count:
109/L Highest ALT:
U/L
Haematocrit:
%
Highest AST:
U/L
PATIENT EXPOSURE HISTORY
Been diagnosed with dengue before?
Been diagnosed with Rift Valley Fever before?
Got Rift Valley Fever vaccination?
Got Yellow Fever vaccination?
Px occupation?
During the past month, did patient travel?
Rash (Appearance)
macular
papular
petechial
urticarial
pruritic
other
YES
NO
UNK
(If admitted)
When?
__/____ (month/year)
__/____ (month/year)
____ (year)
____ (year)
Since : ____ (year)
From:
Until:
__/__/____
__/__/____
Less
Well
days
Haemorrhagic fever
Ocular disease
pain
inflammation
blurred vision
photophobia
↓visual acuity
Where?
Outdoors Another province
Another country
Name of place:
Px had recent bites/unusual animal contact?
__/____ (month/year)
Mosquito bites
Animal bite
Animal blood/tissue
Drank unpasteurized milk
Tick bites
Animal saliva
Animal faeces/urine
Consumed uncooked meat
Other exposures:
POST COMPLETED FORM WITH SPECIMEN TO:
Special Viral Pathogens Lab, National Institute for Communicable Diseases, National
FAX OR EMAIL COMPLETED FORM TO:
Health Laboratory Service, 1 Modderfontein Road, Sandringham 2192, South Africa
0866671391 or cezd@nicd.ac.za