Form Doh 210-040 - Shellfish Poisoning: Paralytic, Domoic Acid
ADVERTISEMENT
1
2Immediately notify
Outbreak-related
LHJ Use
ID ______________________
DOH Communicable
Reported to DOH
Date ___/___/___
Disease Epidemiology
LHJ Cluster#________
_
LHJ Classification
Confirmed
Phone: 877-539-4344
LHJ Cluster
Probable
Shellfish Poisoning:
Name:
By:
Lab
Clinical
________________
____
Epi Link: _________________
Paralytic, Domoic Acid
DOH Outbreak # ____________
County
REPORT SOURCE
LHJ notification date ___/___/___
Investigation start date ___/___/___
Reporter name ________________________
______
___
Reporter (check all that apply)
Lab
Hospital
HCP
Reporter phone ________________________________
Public health agency
Other
Primary HCP name _____________________________
Primary HCP phone _____________________________
OK to talk to case?
Yes
No
DK
Date of interview ___/___/___
PATIENT INFORMATION
Name (last, first) _________________________________________________
_
___
_
__
Birth date ___/___/___ Age _______
Address __________________________________________________
Homeless
Gender
F
M
Other
Unk
City/State/Zip __________________________________________________________
Ethnicity
Hispanic or Latino
Phone(s)/Email ___________________________________________________
__
____
or
Not Hispanic
Latino
Unk
Alt. contact
Parent/guardian
Spouse
Other
Name: ________________
___
Race (check all that apply)
Amer Ind/AK Native
Asian
Zip code (school or occupation): _________________
Phone: __________________
Native HI/other PI
Black/Afr Amer
Occupation/grade _______________________________________________________
White
Other
Unk
Employer/worksite __________________ School/child care name _________
_
_______
CLINICAL INFORMATION
Onset date: ___/___/___
Derived
Diagnosis date: ___/___/___
Illness duration: _____ days
Hospitalization
Signs and Symptoms
Y N DK NA
Hospitalized at least overnight for this illness
Y N DK NA
Mouth tingling or numbness
Hospital name ___________________________________
Breathing difficulty or shortness of breath
Admit date ___/___/___
Discharge date ___/___/___
Weakness
Memory loss
Y N DK NA
Died from illness
Death date ___/___/___
Extremities numb
Autopsy
Place of death _________________
Swallowing or speech difficulty
Eyelids drooping (ptosis)
Laboratory
P = Positive
O = Other
Vision blurred or double
N = Negative
NT = Not Tested
Vomiting
I = Indeterminate
Diarrhea
Maximum # of stools in 24 hours: ____
Collection date ___/___/___ Source _______________________
Clinical Findings
P N I
O NT
Y N DK NA
High levels of associated dinoflagellates in
Ataxia
source water for epidemiologically implicated
Cranial nerve abnormalities (bulbar weakness)
shellfish
Paralysis or weakness
Saxitoxin in epidemiologically implicated food
Acute paralysis
Dysphagia
Domoic acid in epidemiologically implicated
Dysphonia
Cranial nerves
food
Excessive respiratory secretions
NOTES
Respiratory failure
Cardiac arrhythmia
Memory impairment
Confusion
Seizures
Coma
Admitted to intensive care unit
Mechanical ventilation or intubation required
during hospitalization
Case defining variables are in bold. Answers are: Yes, No, Unknown to case, Not asked /Not answered
DOH 210-040 (Rev. 8/5/11)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal