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June 5, 2009
Novel Influenza A (H1N1) Case History Form (Hospitalized and Fatal Cases)
Patients must have 1) a clinical syndrome consistent with influenza or its complications; 2) either probable or confirmed novel
influenza A (H1N1) by laboratory testing; and 3) been either hospitalized OR expired at any location (e.g. hospital, ER, home, etc).
Patient Information CDPH Case ID Number: CA__________________________
Last name ______________________ First name DOB ____/_____/____ Sex: Female Male
Street Address: ________________________ ____________ City ______________________ Zip Code _______________
Race: White Black Native American Asian/PI Other Unknown Ethnicity: Hispanic Non-Hispanic
Date onset of symptom(s): ______/______/______ Vaccination Status
Level of medical care (check all that apply): Was patient vaccinated for influenza this season (at least 14 days
Outpatient clinic ER Inpatient Ward prior to onset of symptoms)? Yes No Unk
PICU None Medical Record #________________ If yes, how many doses: One Two
Recent travel? Yes No If yes, where:________________ If yes, type of vaccine: Inactivated FluMist
Recent ill contacts: Yes No If yes, who:______________ Vaccinated for influenza in prior seasons? Yes No Unk
If hospitalized, Date of admission: _____/_____/_____ Diagnostic/Laboratory Studies
Date of discharge: _____/_____/_____ CBC: Hct ______ Plt ______ WBC______
Symptoms that occurred during the current illness: Chest X-ray: Pos Neg Not done
Fever >38º Cough Sore throat Nausea/vomiting Findings: ___________________________________________
Diarrhea Muscle aches Altered mental status Chest CT: Pos Neg Not done
Findings: ___________________________________________
Shortness of breath Apnea Seizures
Lumbar puncture: Pos Neg Not done
Other; specify______________________________________
Findings:____________________________________________
Complications that occurred during the acute illness: Other pertinent labs (LFTs, MRI/CT, etc.)_________________
Pneumonia/ARDS Bronchiolitis _
2ْ bacterial pneumonia Encephalitis/encephalopathy ___________________________________________________
Myocarditis Sepsis/Multi-organ Failure
Microbiologic Tests [attach copy of microbiology reports]
Other, specify __________________________________ Rapid test done: Yes No Unk If yes: Pos Neg
Was influenza diagnosed by other methods (check all that apply)
Significant Past Medical History (check all that apply)
IFA/DFA PCR Viral culture Other: ________
Cardiac disease Yes No Unk
Influenza type, if known: Influenza A Influenza B Unk
Chronic pulmonary disorder Yes No Unk Rapid RSV test result Pos Neg Not done
Immunosuppressed (e.g. HIV, cancer): Yes No Unk
Other viral/bacterial pathogens detected? Yes No Unk
Metabolic disorder (e.g. DM, renal) Yes No Unk If yes, specify source: Sputum ET asp BAL
Neuromuscular disorder (e.g., seizure disorder, developmental Pleural fluid Blood Other______________________
delay/MR, hypoxic encephalopathy, etc) Yes No Unk
If yes, specify pathogen:_____________________________
Hemoglobinopathy (e.g. SCD): Yes No Unk Other micro results: ___________________________________
Long -term aspirin therapy: Yes No Unk
Genetic disorder (e.g. Downs,) Yes No Unk Clinical course
Immunosuppressive meds (e.g. steroids): Yes No Unk Antivirals (if any), type and dates started:
_______________________________________ ___/___/___
Prematurity: Yes No Unk If yes, #weeks gestation:_____
If hospitalized, intubated? Yes No Unk
Gastrointestinal disease (e.g. GE reflux) Yes No Unk
Died: Yes No If yes, date of death ___/___/___
Pregnant: Yes No Unk If yes, EDC :_____
Other conditions (e.g. obesity): Yes No Unk Hospital Contact Name: _______________________________
If YES for any of the above, please specify: Hospital:____________________________________________
Phone/Pgr:___________________E-mail:_________________
___________________________________________________
LHD Contact Name:__________________________________
___________________________________________________
Phone/Pgr:___________________E-mail:_________________
___________________________________________________
Please forward any available medical records (e.g. H & P, micro reports, discharge summary, autopsy report). Please contact your local health department or CDPH to
report these cases ASAP so that we can assist with collection and shipment of specimens for further laboratory characterization
To report a case, please contact Contra Costa Public Health @ (925) 313-6740 and FAX this form to: (925) 313-6465
To accompany a lab specimen, fax this form to the Public Health Lab @ (925) 370-5252
For questions, contact your local county health department or the California Department of Public Health Viral and Ricketsial Disease Laboratory (510) 307-8585
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