Anaplasmosis case report

Please complete the following information for individuals who have or may have anaplasmosis.

Reporting source

Last name

First name

Agency

Report date

Phone number

Fax number

Email address

Client demographic information

Last name

First name

Date of birth

Sex at birth

Male

Female

Gender

Ontario Health Card

Phone number

Street address

City or town

Postal code

Family health care provider

Family health-care provider phone number (999-999-9999)

Exposure history

History of known tick bite in the two weeks before symptom onset?

Yes

No

Unknown

Did client travel outside of the KFL&A area during the two weeks before symptom onset?

Yes

No

Unknown

Case details

Medical risk factors

Is client immunocompromised due to medical condition or treatment ?

Yes

No

Was the client a recipient of a blood transfusion in the year before symptom onset?

Yes

No

Is there a suspected co-infection with other tickborne disease?

Yes

No

Signs and symptoms

Date of symptom onset

Check all that apply

Fever

Chills

Severe headache

Malaise

Myalgia

Arthralgia

GI symptoms

Other

Hospitalization

Was the client hospitalized due to this illness?

Yes

No

Unknown

Serological testing 1 - Acute

Serological testing 1 - collection date

Acute Serology IFA-IgG Titre

Positive

Negative

Pending

Not performed

Serological testing 2 - Convalescent

Serological testing 2 - collection date

Convalescent Serology IFA-IgG Titre

Positive

Negative

Pending

Not performed

Other diagnostic test(s), specify

Treatment

Has client been treated for Anaplasmosis?

Yes

No

Personal information on this form is collected under the authority of the Health Protection and Promotion Act R.S.O 1990, c. H.7, s.26; R.R.O. 1990, Reg. 569, s.1 (2), amended and in accordance with PHIPA and will be used for assessment, mangement, treatment and reporting purposes. Questions about this collection should be addressed to the Medical Officer of Health at KFL&A Public Health, 221 Portsmouth Avenue, Kingston, ON K7M 1V5 613-549-1232 or 1-800-267-7875.

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Anaplasmosis case report

Reporting source

Client demographic information

Exposure history

Case details

Medical risk factors

Signs and symptoms

Hospitalization

Serological testing 1 - Acute

Serological testing 2 - Convalescent

Treatment