Professional Documents
Culture Documents
Important Instructions: Please complete sections 1-3 for all reportable conditions. In addition, complete Section 4 for STDs and HIV/AIDS cases, Section 5 for hepatitis, and Section 6 for tuberculosis. Once completed, return to your county or tribal health agency. If reporting through MEDSIS, go to https://my.health.azdhs.gov/.
State ID / MEDSIS ID
1. PATIENT INFORMATION
Patients Name (Last, First, Middle) Date of Birth Race (check all that apply): White Pacific Islander Black Native American Asian Other State: Outcome: Survived Died Date: Diagnosis Date Reporting Source (Physician or other reporting source) Date Collected L A B R E S U L T S Date Finalized Specimen Type Blood Stool Other Specimen Type Blood Stool Other Specimen Type Blood Stool Other Lab Test CSF NP Swab Urine Sputum Lab Test CSF NP Swab Urine Sputum Lab Test CSF NP Swab Urine Sputum Lab Result Lab Result Provider (if different from Reporter) Provider Street Address City Facility State Zip code Telephone# Lab Result Street Address City State Zip code Telephone# Facility Unknown Ethnicity: Hispanic Non-Hispanic Unknown County: Gender: Male Female Reservation: Unknown Transgender Pregnant: No Unknown Yes Due date
Zip code:
Telephone#:
Is the patient any of the following? Healthcare worker Food worker/handler Facility Name & Address:
Date Collected
Date Finalized
Date Collected
Date Finalized
5. HEPATITIS PANEL
Hepatitis A Serology Results Hepatitis A Antibody (acute IgM anti-HAV) Hepatitis B Serology Results Hepatitis B surface Antigen (HBsAg) Hepatitis B core Antibody IgM (HBcAb-IgM) Hepatitis B core Antibody Total (HBcAb) Hepatitis B surface Antibody (HBsAb) Hepatitis B e Antigen (HBeAg) Symptoms consistent with acute hepatitis Jaundice Liver Function Test ALT: Hepatitis C Serology Results Hepatitis C-EIA Pos Neg Hepatitis C-RIBA Pos Neg Hepatitis C-NAT/PCR Pos Neg Hepatitis C-Viral Load Liver Function Test ALT: Unk Unk Unk Pos Neg Unk Unk Unk Unk Unk Unk Unk Unk
6. TUBERCULOSIS (TB)
Site of Disease Pulmonary Laryngeal Extrapulmonary
HIV/AIDS Risk Factors IDU Sex with IDU Sex with males Date of Last Negative HIV Test:
Site of Infection Genitalia Rectum Throat Other Patient had Sexual Contact with: Males only Refused Females only Unknown Both Marital Status Married Single Divorced Widowed Separated Domestic partner Unknown Sex Partners: # Sex partners # Sex partners treated
Pos Neg Pos Neg Pos Neg Pos Neg Pos Neg Yes No Yes No AST: s/co ratio:
AST: