Chikungunya Case Investigation Form • Fax It to 602-364-3198

METHODS OF SUBMISSION • Attach form to MEDSIS case • Email it with security to [email protected] (include [secure] in the subject line) Chikungunya Case Investigation Form • Fax it to 602-364-3198 Investigator: ________________________________________________________________ Date of interview: ________________ Patient Information Name _____________________________________________________________________________________________________________ Gender Female Male Unknown Date of Birth __________________________________________ Address ___________________________________________________________________________________________________________ Phone/Cell# ______________________________________________________________________________________________________ Email _____________________________________________________________________________________________________________ Guardian(s) _______________________________________________________________________________________________________ Occupation/School ________________________________________________________________________________________________ Living Situation Correctional facility Crisis center Homeless Hospital Long-term care Military base Multi-family dwelling Residential rehabilitation/Halfway house Residential school Single-family housing Unknown Race Alaskan Indian or Native American Asian Black Hawaiian or Pacific Islander White Unknown Other: _________________________________________________________________________________________ Ethnicity Hispanic or Latino Not Hispanic or Latino Unknown Tribal Affiliation Ak-Chin Cocopah Colorado River Fort McDowell Fort Mohave Fort Yuma Quechan Gila River Havasupai Hopi Hualapai Kaibab-Paiute Navajo Nation Pasqua Yaqui Salt River Pima-Maricopa San Carlos Apache San Juan Southern Paiute Tohono O’odham Tonto Apache White Mountain Yavapai Apache Yavapai Prescott Zuni Out of State Unk Primary Language ___________________________________________________ Can interview in English? Yes No Died Yes Date of death: __________________ No Case Information MEDSIS Case # ____________________ County: __________________________ Initial report date _______________ Classification Confirmed Not a case Probable Suspect Reporter __________________________________________________________________________________________________________ Reporter Organization ____________________________________________________________________________________________ Reporter phone # ______________________________ Email ___________________________________________________________ Provider __________________________________________________________________________________________________________ Provider Organization ____________________________________________________________________________________________ Provider phone # ______________________________ Email ___________________________________________________________ Onset date _______________________ Diagnosis date _______________________ Education & Control Actions Education provided? Yes Offered but declined Not offered N/A Date education provided __________________ Type of education Verbal Written Web-based Other ____________________________________________________________________ Control actions taken Yes No Unknown Symptoms & Outcomes Clinical Picture Unknown Asymptomatic Encephalitis- including Meningoencephalitis Meningitis Other neuroinvasive Other clinical Uncomplicated fever Symptoms (check all that apply, circle primary symptoms) Headache Joint pain Muscle pain Rash Nausea/vomiting/diarrhea Extreme fatigue Joint swelling Muscle weakness Fever (>38° c or 100°F) Max temp ___________ Other (specify) ____________________________________________________________________________________________________________________________ Is the patient hospitalized? Yes Admit date: ________________ No Unk Is the patient breastfeeding a child? Yes No Unk Is the patient a breastfed child? Yes No Unk Medical History Vaccination History Cancer Viral Hepatitis Hypertension Heart disease Yellow fever Date __________________ Pulmonary disease Immunosuppressive condition Japanese encephalitis Date __________________ Diabetes Type: ___________________________ Tick-borne encephalitis Date __________________ Mosquito-borne illness (Dengue, Yellow Fever, Japanese Encephalitis, West Nile virus, St. Louis encephalitis, or Flavivirus) Other medical history (chronic/infectious) ______________________________________________________________________________________________ Risk Factor Assessment Within 14 days of onset of symptoms, did the patient have known mosquito exposure? Yes Dates: _______________________________ Locations:_____________________________________________________________ No Unk Within 14 days of onset of Travel dates/locations: Within 14 days of onset of symptoms, did the patient symptoms, did the patient travel? Date from: ________________________________ donate an organ or tissue? (mark furthest destination point if there Date to: ___________________________________ Yes No Unk was more than one travel destination) Location: __________________________________ Date: ___________________ Yes, outside of US Yes, outside of Arizona Within 14 days of onset of Yes, outside county of residence Date from: ________________________________ symptoms, did the patient No travel history Date to: ___________________________________ donate blood? Unknown Location: __________________________________ Yes No Unk In the 30 days prior to onset of symptoms, did the patient receive blood or blood product? Yes No Unk In the 30 days prior to onset of symptoms, did the patient receive an organ or tissue transplant? Yes No Unk Acquired? In utero In a laboratory Occupationally (non-lab) Length of illness (days) ___________ Discharge date, if hospitalized ______________________ Outcome: Died Full recovery Recovery with sequelae, describe: _____________________________________________________________ Treatment description: ____________________________________________________________________________________________ Notes: Revised 4/27/17 .

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