CASES NOTIFICATION
EPIDEMIOLOGICAL SURVEILLANCE GROUP IN HISTOPLASMOSIS
[QUESTIONNAIRE PER PATIENT]
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Reg. No.
Date:
Responsable physician:
Laboratory:
Institutional Affiliation:
Institution:
Ciudad:
País:
PATIENT DATA
Name:
Sex:
M
F
Age:
Status:
Phone:
Schooling:
No informado
Profesional
Media Superior
Secundaria
Primaria
Lee y escribe
Analfabeta
Occupation:
Period: (occupation)
Address:
County:
State:
GEOGRAPHIC INDICATORS
State/country of origin:
State/country of residence:
State/last 5 years residence:
Residence:
USA, Canada
Period:
Central America, South America
Period:
ANTECEDENTS
Have you been tested for HIV
When:
%CD4:
CD4/mm
3
:
Your partner
When:
%CD4:
CD4/mm
3
:
PERSONAL DATA
Alcoholism:
Drugs:
Immunizations:
Allergy:
Corticosteroid therapy
Reason:
OCCUPATIONAL RISKS
Bat guano contact
Reason:
Period:
Bird guano contact
Reason:
Period:
Have you visited caves/mines/abandoned buildings?
Reason:
Period:
Do you work with any fungus?
Reason:
Period:
Fungus:
PREVIOUS OR ASSOCIATED PATHOLOGIES
Cardiopathies
Coagulopaties
Enfermedades renales
Transplants
Cancer
Anemia
Diabetes mellitus
Leprosy
Tuberculosis
Other bacterial infections
Malaria
Toxoplasmosis
Previous pulmonary diseases
SIGNS AND SYMPTOMS IN THE LAST SIX MONTHS
Cough
Dyspnea
Weight loss about 10%
Chronic diarrhea
Diaphoresis
Asthenia/adynamia
Odynophagia
Hepato/splenomegaly
Fever:
Continued
Vespertina
without fever
CLINICAL DIAGNOSIS
Clinical manifestations:
Course:
New case
Endogenous reinfection
Exogenous reinfection
LABORATORY
Culture:
Histopathology:
Direct observation:
RADIOLOGY
Date:
Observations:
HUMORAL TESTS
Antibodies detected in:
Serum
SF
Tests:
PT
ID
CF
ELISA
Antigens detected in:
Serum
SF
Urine
Tests:
PT
ID
CF
ELISA
CELLULAR TESTS
Histo/PPD
ST: 24h
/
mm
48h
/
mm
72h
/
mm
Histo/PPD
LT: Ag
/
mm
PHA
/
mm
Con A
/
mm
HLA
Class I:
Class II:
Class III:
OPHTALMOLOGICAL EVALUATION
Previous ocular diseases:
Medicines:
Period:
Ametropia
Ocular fundus exploration:
Ophtalmologic clinical studies:
Comments:
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