Form B: Suspected Infection with Bartonella species: Information for Diagnostic Specimens
To accompany all specimens submitted to VRZB/CDC for routine diagnostic testing for Bartonella species.
Call 404-639-1075 if you have questions on how to fill out this form.
Patient Name: ______
Patient DOB ____/____/______
Patient State of Residence: ______
Patient City of Residence: ______
CLINICAL HISTORY
Date of Onset of Symptoms ____/_____/______
First reported symptom ______
Date of Specimen Collection ____/_____/______ whole blood (EDTA) serum node aspirate/ biopsy (type______)
Date of Specimen Collection ____/_____/______ whole blood (EDTA) serum node aspirate/ biopsy (type______) Date of Specimen Collection ____/_____/______ whole blood (EDTA) serum node aspirate/ biopsy (type______)
Clinical Signs and syndromes (check all that apply)
lymphadenopathy (nodes involved ______)
fever (maximum______) blister or papule at site of injury endocarditis
myalgia rash (type______) encephalopathy
malaise peliosis hepatitis neurologic sequelae (specify ______)
headache bacilliary angiomatosis splenic granulomata
weight loss photophobia hepatic granulomata
arthralgia color vision disturbance hepatomegaly
leg pain Parinaud’s oculoglandular syndrome splenomegaly
pallor neuroretinitis osteolytic lesions (location ______)
jaundice conjunctivitis
retro-orbital pain other (specify ______)
Laboratory Values (specify units if different from below)
ALT (U/l) ______WBC (K/l) ______Platelets (K/l) ______
AST (U/l) ______Neutrophils (%) ______Hematocrit (%) ______
CRP (mg/l) ______Lymphocytes (%) ______Hemoglobin (%) ______
Was the patient hospitalized because of this illness? yes no unknown
If Yes, Date of hospital admittance: ____/_____/______
Date of hospital discharge:____/_____/______
Was this a fatal infection? yes no unknown
What sources of illness have been ruled out?______
Treatment: Date started: ____/____/______Other Conditions:
Tetracycline/Doxycycline yes no unknown immuno-compromised
Chloramphenicol yes no unknown immuno-suppressed
Fluoroquinolone yes no unknown pregnant
Erythromycin yes no unknown cardiac or valve disease
Rifampin yes no unknown alcoholic
Other (specify)______ yes no unknown other (specify ______)
EXPOSURE HISTORY
In the month prior to illness onset:
Did the patient have contact with any of the following animals?cat dog rodentother (specify ______)
Is the animal a pet in the patient’s home?yes no unknown
If not, approximate date of contact: ____/____/______
What was the nature of the contact? bite scratch lickother (specify ______)
Approximate age of the animal ______
Did the animal have fleas? yes no unknown
Was patient bitten by or exposed to any fleas during this time? yes no unknown
Was the patient exposed to lice or to persons with lice? yes no unknown
What type of louse?body head pubic
Did the patient travel out of their state of residence?yes no unknown where? ______
CDC Use Only: DASH #______Accession #______Patient #______