ALABAMA DEPARTMENT of PUBLIC HEALTH
 
Zika Virus Disease Consultation Form for Testing Approval for Persons Age 14 and older

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.

* Date form completed

* Patient Last Name

* Patient First Name

Patient Middle Name

* Date of Birth

* Age in Years

* Gender

Female Male

* Does patient have a pregnant partner?

Yes No

* Pregnant?

Yes No Not Applicable (If Male)

If Pregnant, expected delivery date

OR Date of last menstrual period

*Race
(Select all that apply)

American Indian/Alaska Native  
Asian  
Black/African American  
Native Hawaiian/Pacific Islander  
White/Caucasion  
UNKNOWN  

* Ethnicity

Hispanic Not Hispanic Unknown

* Street Address

Apt/Unit Number

* City

* State

* Zip Code

* County

* Phone Number
Include area code and enter as ###-###-####

Alternate Phone Number

Clinical Information

*Patient Symptoms
Check ALL that apply

Asymptomatic  
Fever  
Rash  
Arthralgia/Myalgia  
Conjunctivitis  
Guillian-Barre Syndrome  
Neurologic manifestation  
Other  

Complications of pregnancy including:
fetal loss, or fetus or neonate with congenital microcephaly or intracranial calcifications

Yes No Not Applicable

If Yes: Date (Provide detail in Clinical Notes below)

Date of Symptom Onset
MUST enter if Symptom(s) checked above

Other Symptoms:
Specify

* Hospitalized

Yes No Unknown

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)

* 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)?

Yes No

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

* 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

Yes No

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?

Yes No Unknown

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?

Yes No Unknown

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?

Yes No Unknown

If Yes: List travel locations AND dates of partner travel:

* 3A. Did the patient receive a blood transfusion, organ or tissue transplant during the 30 days prior to illness onset or specimen collection?

Yes No Unknown

If Yes:

Date of transfusion or transplant

Hospital name

* 3B. Has the patient donated blood, tissue or organs in the past 30 days?

Yes No Unknown

* 4A. Did the patient work with Zika/flavivirus agents in a laboratory?

Yes No Unknown

Most recent date:

If Yes:

Laboratory name

Known laboratory exposure to Zika/flavivirus?

Yes No

If Yes: Date of Exposure:

* 4B. Did the patient have a known exposure to blood or bodily fluids?

Yes No Unknown

If Yes: Date of Exposure:

Describe exposure:

* 5. Did the patient share needles with another person?

Yes No Unknown

If Yes: Most recent date:

* 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)

Yes No

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)

Yes No

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.

* Provider Name and Degree(s)

* Facility Name

* Facility Contact Name

* Facility Contact email

* Facility Contact Phone Number

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