BLASTOMYCOSIS CASE REPORT FORM
Please fax completed form to Dr. Joni Scheftel at 651-201-5743
A.
DEMOGRAPHIC INFORMATION
B.
ILLNESS HISTORY
C.
LABORATORY INFORMATION
D.
CASE SUMMARY
Patient Name: ___________________________________
Parent Name (if minor): ____________________________
Address: ________________________________________
City: __________________________ Zip: _____________
County: _________________________________________
Phone (1): ______________ Phone (2): ______________
DOB: ____/____/____
Age: __________________
Sex:
Male
Female
Occupation: _____________________________________
Race: (check all that apply):
American Indian or Alaska Native
Asian
Black
Native Hawaiian or Pacific Islander
White
Unknown
Other: _____________
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Unknown
Physician Name: __________________________________
Institution/Clinic: _________________________________
City: ___________________________________________
Phone: ________________
Person reporting: _________________________________
Phone: ________________
Patient hospitalized?
Yes
No
If yes, hospital name: ____________________________
Admit date:____/____/____
Discharge date:___/____/____
Symptoms:
Illness onset date:____/____/____
Cough
Yes No
Recovery date:____/____/____
Coughing up blood
Yes No
First visit to health care provider:____/____/____
Non-healing skin sores
Yes No
Patient immunocompromised?
Yes No
Poor appetite
Yes No
Explain:_____________________________________
Weight loss
Yes No #lbs.____
Treatment:
Headache
Yes No
Itraconazole
Fluconazole
Back pain
Yes No
Voriconazole
Amphotericin B
Chest pain
Yes No
Other:_____________
Bone pain
Yes No
Did patient die?
Yes No
Joint pain
Yes No
If yes, date:____/____/____
Fever
Yes No temp. ___F
Did patient die as a result of blastomycosis?
Chills
Yes No
Yes No
Night sweats
Yes No
If no, cause of death: ________________________
Fatigue
Yes No
Other symptom: __________________________________
Lab name: _______________________________________ MDH #: _________________________________________
Culture:
Smear:
Antigen Testing:
Collection date:____/____/____
Collection date:____/____/____
 Urine  Serum
Result:
Pos Neg
Result:
Pos
Neg
Collection date:____/____/____
DNA probe:
Yes
No
DNA probe:
Yes
No
Result:
Pos Neg
Specimen: ______________________ Specimen: ______________________ Value: ________________________
Serology/Antibody:
Histopathology:
Radiology/Imaging:
Collection date:____/____/____
Collection date:____/____/____
Location: ______________________
 AGID
 Elisa
Result:
Pos
Neg
Xray Date:____/____/____
 Comp FX  EIA
Specimen: ______________________ CT Date:____/____/____
Result:
Pos Neg
MRI Date:____/____/____
Results: ________________________
Type of blastomycosis (check all that apply):
Pulmonary, disease present only in the lungs
Extra-pulmonary, no disease in lungs
Minnesota Dept. of Health
PO Box 64975, 625 N Robert St.
St. Paul, MN 55164-0975
Phone: 651-201-5414 | Fax: 651-215-5743
Disseminated, both pulmonary and extra-pulmonary lesions
Bone
Eye
Skin
CNS
Other location: _________________________________
3/2016