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Patient Information
All fields with an "*" must be completed for all patients. Complete all additional fields as applicable. Month, day and year MUST be entered for all applicable date fields - if uncertain of exact date(s), enter the best estimate and make a note in the "Clinical Notes" section. Please note that incomplete information may require follow up with the provider to obtain the required information and delay an approval decision.
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Date form completed
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Patient Last Name
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Patient First Name
Patient Middle Name
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Date of Birth
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Age in Years
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Gender
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Does patient have a pregnant partner?
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Pregnant?
If Pregnant, expected delivery date
OR Date of last menstrual period
*Race
(Select all that apply)
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Ethnicity
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Street Address
Apt/Unit Number
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City
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State
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Zip Code
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County
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Phone Number
Include area code and enter as ###-###-####
Alternate Phone Number
Clinical Information
*Patient Symptoms
Check ALL that apply
Complications of pregnancy including:
fetal loss, or fetus or neonate with congenital microcephaly or intracranial calcifications
If Yes: Date (Provide detail in Clinical Notes below)
Date of Symptom Onset
MUST enter if Symptom(s) checked above
Other Symptoms:
Specify
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Hospitalized
If Yes: Admit Date
Reason:
Hospital name
Patient Status
(Inpatient, Discharged, etc.)
Clinical Notes
Exposure Information
Prior to symptom onset (or specimen collection if asymptomatic)
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1. Did the patient travel to or live outside their local area in the 14 days before onset of symptoms (or specimen collection if asymptomatic)?
If yes, Country(s) or City(s) and US State/Territory (include address(s) for domestic locations, if known):
International locations with active Zika transmission are listed here: http://www.cdc.gov/zika/geo/active-countries.html. US locations with travel advisories are listed here: http://www.cdc.gov/zika/geo/index.html
Travel Start Date
Travel End Date
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2A. Did the patient have sexual contact* without a barrier method in the past 8 weeks?
*vaginal sex (penis-to-vagina sex), anal sex (penis-to-anus sex), oral
sex (mouth-to-penis sex or mouth-to-vagina sex), or the sharing of sex toys
Date of Most Recent Occurrence:
If yes, answer 2B-2D:
2B. Had any of the persons with whom the patient had sexual contact been diagnosed with Zika virus infection?
2C. Did any of the persons with whom the patient had sexual contact have symptoms of illness like fever, rash, joint pain, or red eyes?
2D. Did any of the persons with whom the patient had sexual contact travel or might have traveled to a country, US state or territory with known local Zika transmission in the previous 6 months?
If Yes: List travel locations AND dates of partner travel:
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3A. Did the patient receive a blood transfusion, organ or tissue transplant during the 30 days prior to illness onset or specimen collection?
If Yes:
Date of transfusion or transplant
Hospital name
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3B. Has the patient donated blood, tissue or organs in the past 30 days?
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4A. Did the patient work with Zika/flavivirus agents in a laboratory?
Most recent date:
If Yes:
Laboratory name
Known laboratory exposure to Zika/flavivirus?
If Yes: Date of Exposure:
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4B. Did the patient have a known exposure to blood or bodily fluids?
If Yes: Date of Exposure:
Describe exposure:
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5. Did the patient share needles with another person?
If Yes: Most recent date:
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6. Did the patient provide materials from the Alabama Department of Public Health that indicated they should be tested for Zika?
(e.g., letter, flyer or door hanger indicating that Zika activity was present in their area)
If NONE of the exposure questions (Q1-6) are "Yes":
7. Is there additional clinical information that you wish to be considered for testing approval?
(e.g., 2 or more symptoms with no alternate diagnosis)
If Yes, please describe:
Note: an ADPH physician may contact you to review the information provided, so provide as much detail as possible and include on-call contact information to ensure that additional discussion or requested information may be obtained as soon as possible to expedite testing approval and/or recommendations
Provider Information
NOTE: the facility contact should be the individual, phone number and email that will provide the most rapid follow up should specimen collection and/or additional information be required for testing approval.
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Provider Name and Degree(s)
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Facility Name
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Facility Contact Name
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Facility Contact email
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Facility Contact Phone Number
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