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 Rabies

Possible Human Rabies -- Patient Information Form

A copy of this form must accompany diagnostic specimens. Send completed form to:

Please print the following form and fill it out as completely as possible. The first three sections are required (Patient Information, Symptoms, and Laboratory Findings).

Hint: In order to print this form WITHOUT the left navigation, click on "Printer-friendly version" in the upper-right corner of this page.

Patient Information:

Date (mm/dd/yy):
Physician's Name:
Physician's Phone Number:
Patient's Name:
Gender Female Male
Patient's Date of Birth (mm/dd/yyyy):
Occupation:

Symptoms:

Which of the following symptoms have been present? Mark all that apply.

  Yes No Unknown
Fever
Malaise
Headache
Nausea/vomiting
Anxiety
Muscle Spasm
Dysphagia
Anorexia
Ataxia
Priapism
Seizures
Aerophobia
Hydrophobia
Localized weakness
Localized pain/paraesthesia
Confusion or delirium
Agitation/combativness
Autonomic instability
Hyperactivity
Hallucnations
Insomnia
Hypersalivation

Laboratory Findings:

Peripheral WBC (with diff): On admission x103/µl
  neutrophils %     
  lymphocytes %     
  monocytes %     
  bands %     
  Highest x103/µl
  neutrophils %     
  lymphocytes %     
  monocytes %     
  bands %     
Chemistry: Glucose, serum mg/dl
  Total protein, serum g/dl   
  CPK, serum - total U/l    
  Isoenzymes - MM %     
  MB %     
  BB %     
CSF Findings: RBC /µl     
  WBC /µl     
  neutrophils %     
  lymphocytes %     
  monocytes %     
  bands %     
  Glucose mg/dl
  Protein mg/dl

Culture Results:

Additional Abnormal Laboratory Values:

Additional Pertinent Clinical Information:

Additional Information:

Location of residence at time of onset: 1. Urban 2. Suburban 3. Rural
City:
State:
   
Has the patient traveled to any foreign country in the past six months?
Country 1:
Number of weeks:
Country 2:
Number of weeks:
   
Any suspicious animal exposures? Yes No
Date of exposure (mm/dd/yy):
Species involved in most recent exposure: Dog
  Cat
  Raccoon
  Skunk
  Fox
  Bat
  Other, specify:
   
Type of exposure: Bite
  Nonbite (scratch)
  Nonbite (contact only)
  No known exposure
  Unknown
   
City and state of most recent exposure:
Species involved in previous exposure: Dog
  Cat
  Raccoon
  Skunk
  Fox
  Bat
  Other, specify:
Date of exposure (mm/dd/yy):
Type of exposure: Bite
  Nonbite (scratch)
  Nonbite (contact only)
  No known exposure
  Unknown
   
City and state of previous exposure:
First symptoms:
   
Date of illness onset (mm/dd/yy):
Outpatient visit date (mm/dd/yy):
Outpatient diagnosis:
   
Hospitalized? Yes No
Date of hospitalization (mm/dd/yy):
Admitting diagnosis:
   
Is/was patient in a coma? Yes No
Date of coma onset (mm/dd/yy):
Has patient expired? Yes No
Date of death (mm/dd/yy):
Current differential diagnosis:

Page last modified: September 28, 2007
Content Source: National Center for Zoonotic, Vector-Borne, & Enteric Diseases (ZVED)