APPENDIX V 
PHS 3.332 (CDC) 
REV 3-64 
Patient's Name 
Address 
City 
County 
Age Race 
Occupation 
Dote Onset 
Clinical Diagnosis 
Physician 
Address 
DEPARTMENT OF 
HEALTH. EDUCATION. AND WELFARE 
Public Health Service Communicable Disease Center 
Laboratory Branch Virology Section 
Atlanta, Georgia 30333 
REQUEST FOR VIRAL AND RICKETTSIAL REFERENCE SERVICE 
State 
Sex 
Local File No. 
State Approval 
Referral 
Other Source 
LABORATORY EXAMINATION REQUESTED: 
Suspected Virus Group 
VIRUS: Isolation Identification 
SEROLOGY OTHER 
REASON FOR REQUEST: 
Epidemic Investigation 
Surveillance Activities 
Epidemiologic Survey 
Other 
OTHER CLINICAL DATA: 
DATES OF PERTINENT IMMUNIZATIONS 
Adenovirus 
Influenza 
Polio - Salk: No. , 
Oral: Type 
Smallpox Other 
Spotted Fever 
Typhus 
Yellow Fever 
Rabies 
Measles 
EPIDEMIOLOGICAL DATA 
Recent Travel (Location) 
Family Contacts 
Community Contacts 
Animal Contacts 
Arthropod Contacts: Mosquitos Ticks Sandflies Other Arthropods 
Bite 
Exposure only 
SIGNS AND SYMPTOMS 
Fever: Height 
Duration 
* 
Rash : (Type) 
Mucous Membrane lesions 
Respiratory: 
Rhinitis 
Pharyngitis 
Pneumonic involvement 
Cardiovascular: 
Myocarditis 
Pericarditis 
Gastrointestinal: 
Diarrhea 
Constination 
Abdominal pain 
Vomiting 
(Continued on Reverse Side) 
43 
