Lyme Disease Case Report Form

Patient Information:

            Name 
  Street address 
 Address (cont.) 
            City 
  State/Province 
 Zip/Postal code 
         Country 
      Work Phone 
      Home Phone 
          E-mail 

Please identify and describe yourself:

   Date of birth 
        Sex      Male Female

 

Symptoms and Signs of Current Episode (please mark each question)

Dermatologic:
Erythema migrans (physician diagnosed EM at least 5 cm in diameter)?

Yes
No
Don't Know

Rheumatologic:
Arthritis characterized by brief attacks of swelling in one or a few joints?

Yes
No
Don't Know

 

Neurologic:

Bells palsy or other cranial neuritis?

Yes
No
Don't Know

Radiculoneuropathy?

Yes
No
Don't Know

Lymphocytic meningitis?

Yes
No
Don't Know

Encephalitis?

Yes
No
Don't Know

Antibody to B. burgdorferi higher in CSF than serum?

Yes
No
Don't Know
Not Tested

Cardiologic:
Second or third degree atrioventricular block?

Yes
No
Don't Know

Other Clinical Symptoms:

Other History

Date of onset of first symptoms:

-- mm/dd/yy

Date of diagnosis:

-- mm/dd/yy

Date of report to health agency:

-- mm/dd/yy

Was the patient hospitalized for the current episode?

Yes
No
Don't Know

Name of antibiotics used in this episode and number days of use ... in the space provided below.

Was the patient pregnant at the time of the illness?

Yes
No
Don't Know

Where was the patient most likely exposed? Enter county and state... in the space provided below.

Laboratory Results

Serologic test results:

Positive
Negative
Equivocal
Not done/Unknown

Culture results:

Positive
Negative
Equivocal
Not done/Unknown

Other(specify):

Positive
Negative
Equivocal
Not done/Unknown

Physician information:

            Name 
  Street address 
 Address (cont.) 
            City 
  State/Province 
 Zip/Postal code 
         Country 
      Work Phone 

Person completing form information:

            Name 
  Street address 
 Address (cont.) 
            City 
  State/Province 
 Zip/Postal code 
         Country 
      Work Phone