LABORATORY EXAMINATIONISl REQUESTED (31 3bi 



n ANiimicrobtal Susceptibility D IDentif ication D SErologv (Specify Test). 

 D Histology D isolation D OTher (Specify) 



CATEGORY OF AGENT SUSPECTED (37J D Bacterial D Viral D Fungal D Rickettsial D Parasitic D Othei (Specify I . 



SPECIFIC AGENT SUSPECTED 



■ 136-401 I 



OTHER ORGANISMISI FOUND 



ISOLATION ATTEMPTED' (47| D Yes D No NO TIMES ISOLATED 148 49| 



SPECIMEN SUBMITTED IS IS?): D Original Material D Puie Isolate D Mined Isolati 



NO TIMES PASSED (50 511. 



J_±_L 



ORIGIN (59-60) 



D HUman 



n FOod 



Dsoii 



C ANimal (specify) . 

 D OTtier (Soecrlyl . 



URine D CSF D HAir D SKin 



I I I D Tissue (Specify) 



I . I D OTher (Specify) 



SOURCE OF SPECIMEN 161 6.-11 D BLood DgAshic D SErum D SPutum D 

 n wound (Site) 



n STool n THroat 



D Exudate (Site) . 



SUBMITTED ON (63-64) D MEdium (Specify) , 

 D ANimal (Specify) - 



• I 



D EGg n Tissue Culture (Type) 

 D OTher (Specify) 



SERUM INFORMATION 



(65-721 

 173-801 

 {81-881 

 (89-96) 

 (97-104) 



D ACute 



Cj convalescent 



ns3 

 ns4 



Dss 



IMMUNIZATIONS: 



.dZL 



TREATMENT: Drugs Used D None (129) Dale Begun 



Mo. Da. Y 



Date Completed 

 Mo. Da. Yr, 



l-ia3) 

 1-157) 

 l-Wl) 



EPIDEMrOLOGICAL DATA: (172 173) 



n single Case D Sporadic D COntact D EPidem.c D CArner 



Famitv Illness (l '*»- 



Communitv Illness _(176- 



Travel and Residence (Location! . . — 



n Foreign (178-183) I— --L_ 



D USA — ^1184.189) L_l_ 



1751 I 



177)111 



, Mo. 



Animal Contacts (Species) (190- 



Arthropod Contacts (192) D None D Exposure Only D Biie 



Type of Arthropod (193- 



Suspected Source ot Infection ( 195 



, n~i 



ig-i) l_ 



196)L 



PREVIOUS LABORATORY RESULTS/OTHER CLINICAL INFORMATION: 



CLINICAL TEST RESULTS 



Sputurn and Histological Findings- 

 Blood Counts 



■(12 13)1 0|2 I 



Type Skin Tests Performed 



Strength Pos. Neg. 



(22) 

 (31) 

 (40) 



SIGNS AND SYMPTOMS 



(48-49) D FEver 



Maximum Temperature . 

 Duration Days 



(56-57, DCH-lls <^^-"' 



RASH: 



(58-59) n MAculopapular 



(60-61) D HEmofrhagic 



(62 63) D VEsiCular 



(64-65) D Erythema Nodosum 



(66-67) D Erythema Marginatum 



(68-69) D OTher 



RESPIRATORY: 



(70 71) D RHinitis 



(72 73) n Pulmonary 



(74-75) n PHaryngitis 



(76 77) D CAIcifications 



(78-79) n PNeumonia (type) 



(80-81) D OTher 



CARDIOVASCULAR: 



(82-83) D MYocardilis 

 (84-85) Q PEricarditis 

 (86-87) n ENdocarditis 

 (88-89) D OTher 



GASTROINTESTINAL: 



(90-91 ) D Diarrhea 

 (92-93) D BLood 

 (94-95) n MUcOus 

 (96-97) n constipation 

 (98-99) n ABdominal pam 



(100-101) D VOmiiing 



(102-103) D OTher 



FOR CDC USE ONLY [Ojjjd? 13) 



TYPE SERVICE: (14 15) 

 Ql-Relerence 

 02-Eoid, Aid 

 03-Proficiency Testing 

 04-Speciai Projects 



L_ 



_l - Other 



No Specimens (16-20) 

 LOCATION CODE: (26-27) 



AR Mrgentma 

 AS Australia 

 AU Austria 

 BC BermuOa 

 BE Belgium 

 BH British Hon 

 BL Bolivia 

 BR Brazil 

 CA Canada 

 CB Cambodia 



CM Cameroon 



CO Colombia 



C5 Costa Rica 



CY Cyprus 



DR Dominican I 



EC Ecuador 



ES El Salvador 



ET Ethiopia 



FR France 



GE Germany 



GQ Guam 



GT Guatemala 



HA Haiti 



HO Honduras 



IN India 



IS Israel 



IT Italy 



IV Ivory Coast 



JM Jamaica 



MX MftxiCO 



MV Malaysia 



Nl Nigeria 



No Tests (21-25) 



SPECIMEN SUBMITTED BY: (28-30) 



NU Nicaragua 

 NZ New Zelan 

 PA Paraguay 



PN Panama 

 PP New/ Gull 

 RP Ptiilippines 



gdorr 



jerto Rico 

 Sierra Leone 

 Spam 



TH Thailand 



TVi/ Taiwan 



UK United Kii 



UR Soviet Un 



UY Uruguay 



VE Venezuela 



VN Vietnam 



VQ Virgin Islands 



100-Health Dept. 



200-CDC Clinic 



202-Bioloqical Reagents 



205-Proficiency Testing 



214-S.E.P. 



301-Army 



302-Navy 



303-Aii Force 



307 V. A. Hosp. 



310-U.S.D.A. 

 321-F.D.A. 

 323-lndian Hosp. 

 324-PHS Hosp. 

 550-Unlverslty 

 60e-Physlclan/Cllnic 



CDC 3 203 (BACK) 

 REV 4-76 



CDC Number L. 



146 



