State of California
- Health and Human Services Agency
California Department of Public Health
SEVERE INFLUENZA CASE HISTORY FORM
(ICU AND FATAL CAS
ES)
CASE STATUS (check all that apply)
ICU
A case with laboratory-confirmed influenza requiring admission to an intensive care unit (ICU)
Fatal A case with laboratory-confirmed influenza that has died at any location (e.g. hospital, emergency, home)
First name Date of birth
City Zip code Local health jurisdiction of residence
Ethnicity
Race (Check all that apply):
☐ White ☐ Black or African American ☐ American Indian or Alaska Native ☐ Asian
☐ Native Hawaiian or Pacific Islander ☐ Unknown ☐ Other: _______________________
ONSET, VACCINATION HISTORY, HOSPITALIZATION AND DEATH INFORMATION
Date of onset of symptoms
Received this season’s influenza vaccine?
Yes No
Unknown
If hospitalized, hospital name and location
Date of hospital admission
Date of hospital discharge
If died, location of death (i.e. home, ED-name of hospital ED, etc.)
If died, autopsy performed?
Yes No Unknown
INFLUENZA LABORATORY TESTING INFORMATION (Please attach a copy of the test result, if available)
Date of specimen collection
Specimen type (e.g. nasopharyngeal swabs, endotracheal aspirate, bronchoalveolar lavage)
Influenza type and/or subtype
Influenza A: ☐(H3) ☐
(H1)pdm09 ☐(A Unknown – PCR) ☐(A Unknown – rapid test, culture or DFA)
☐(A – unsubtypable (i.e. novel))
Influenza B: ☐(Yamagata) ☐(Victoria) ☐(B Unknown – PCR) ☐(B Unknown – rapid test, culture or DFA)
Where was testing performed?
REPORTING AGENCY INFORMATION
Reporting local health jurisdiction
Telephone number of reporter
CDPH 9070 (updated 07/19) The information requested on this form is required by the California Department of Public Health for purposes of identification and public health investigation.
Received antiviral treatment?
Yes No Unknown
Type of antiviral
Oseltamivir Zanamivir Other Specify other: _____________________________________________
Date antiviral treatment started
Date antiviral treatment ended
Intubated?
Yes No Unknown
Complications
Pneumonia ARDS Sepsis Acute renal failure Encephalitis/encephalopathy Required vasopressor Required hemodialysis
Pulmonary embolus Secondary bacterial infection If yes, specify organism: ___________________________________________________
Other Specify other: ___________________________________________________________________________________________________
SIGNIFICANT PAST MEDICAL HISTORY
Did the patient have underlying medical conditions?
Yes No
Unknown
Cardiac disease
Chronic pulmonary disorder
Immunosuppression (e.g. cancer)
Immunosuppressive medications (e.g. chemotherapy, steroids)
Metabolic disorder (e.g. diabetes mellitus, renal)
Neurological disorder (e.g. cerebral palsy)
Hemoglobinopathy (e.g. sickle cell disease)
Genetic disorder (e.g. Downs)
Obesity If obese, BMI (if known): _____ Height: _____ Weight: _____
Pregnant If pregnant, estimated delivery date: _______________
Postpartum If postpartum, delivery date: _______________
Other conditions (e.g. hypertension, hyperlipidemia)
If yes for any of the above, please specify:
___________________________________________________________________________________
NOTES SECTION (Please attach relevant medical records if available)
PATIENT INFORMATION
Last name
Street address
Gender
☐ Hispanic
☐ Non-Hispanic
☐ Unknown
San Francisco Department of Public Health
Phone: 415-554-2830
Fax: 415-554-2848
