6a Medical History

Study ID: __ __ __ __ __ __ __ __ __ __
CEIRS Human Influenza Surveillance Study
Form 6A: Medical History
The following questions are about the subject’s recent medical care and medications.
1. ED arrival
Arrival Date: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)
Arrival Time: __ __ : __ __ (hh:mm) (24-hour clock)
2. Has the subject been admitted to the hospital (i.e. stayed overnight) within the past 30 days?

□ No □ Yes □ Unknown
If Yes,
a. For how many days was the subject admitted?
__________Days
b. When was the subject discharged?
_____/_____/________ (mm/dd/yyyy)
3. Has the subject taken any antibiotics within the past 30 days?

□ No □ Yes □ Unknown
a. If Yes, how many antibiotics were taken?

__________Antibiotics

For each antibiotic received, specify the antibiotic name, date started, days taken, and condition it was prescribed
for (i.e. indication; If unknown, please write “unknown”).
Antibiotic 1
Name: _____________________________________
Date started: _____/_____/_______ (mm/dd/yyyy)
Days taken for: __________________________Days
Indication: __________________________________
Antibiotic 2
Name: _____________________________________
Date started: _____/_____/_______ (mm/dd/yyyy)
Days taken for: __________________________Days
Indication: __________________________________
Antibiotic 3
Name: _____________________________________
Date started: _____/_____/_______ (mm/dd/yyyy)
Days taken for: __________________________Days
Indication: __________________________________
Antibiotic 4
Name: _____________________________________
Date started: _____/_____/_______ (mm/dd/yyyy)
Days taken for: __________________________Days
Indication: __________________________________

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Form 6A: Medical History

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Study ID: __ __ __ __ __ __ __ __ __ __
4. Has the subject taken any influenza antivirals within the past 30 days?

□ No □ Yes □ Unknown
Examples are: Oseltamivir (Tamiflu), Zanamivir (Relenza), Amantadine (Symmetrel), or Rimantadine
(Fluadine)
If Yes,
a. Name of influenza antiviral
b. Date the subject started the antiviral: _____/_____/_______ (mm/dd/yyyy)
c. How many days did the subject take the antiviral for? __________Days
5. Is the subject currently taking steroids (pill or injections)?

□ No □ Yes □ Unknown
If Yes, how many steroids is the subject taking? ___________Steroids
For each steroid, specify the steroid name and dose.
Steroid 1
Name: _________________________
Dose: _________________________
Steroid 2
Name: _________________________
Dose: _________________________
Steroid 3
Name: _________________________
Dose: _________________________
Steroid 4
Name: _________________________
Dose: _________________________
6. Is the subject taking any medications that suppress their immune system?

□ No □ Yes □ Unknown
If Yes, which medications (Check all that apply*)
_____ Methotrexate
_____ Tacrolimus (Propgraf)
_____ Mycopehnolate (Cellcept)
_____ Other, specify: ____________________
* Please see Appendix 4 for a list of additional immunosuppressive medications

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Form 6A: Medical History

Version 2.0
01/05/2015

Study ID: __ __ __ __ __ __ __ __ __ __
Medical History
The next few questions are about the subject’s overall medical history.
7. Does the subject have Chronic Lung Disease?

□ No □ Yes □ Unknown

If Yes, does the subject have:

□ No □ Yes □ Unknown
□ No □ Yes □ Unknown
□ No □ Yes □ Unknown

Asthma?
COPD?
Cystic Fibrosis?

Other, specify: ____________________________
8. Does the subject have any Cardiovascular Disease?

□ No □ Yes □ Unknown
If Yes, does the subject have:

□ No
□ No
□ No
□ No
□ No

Coronary Artery Disease?
Congestive Heart Failure?
Cardiomyopathy?
Vascular Disease?
Congenital Heart Disease?

□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown

Other, specify: _____________________________

□ No □ Yes □ Unknown

9. Does the subject have Renal Disease?
If Yes, does the subject have:

□ No □ Yes □ Unknown

End Stage Renal Disease?

Other, specify: _____________________________
10. Does the subject have any Hepatic Disease?

□ No □ Yes □ Unknown

If Yes, does the subject have:
Cirrhosis?
Hepatitis B?
Hepatitis C?

□ No □ Yes □ Unknown
□ No □ Yes □ Unknown
□ No □ Yes □ Unknown

Other, specify: _____________________________
11. Does the subject have any Endocrine/ Metabolic Disorders?

□ No □ Yes □ Unknown
If Yes, does the subject have:
Diabetes?
Thyroid Disorder?

□ No □ Yes □ Unknown
□ No □ Yes □ Unknown

Other, specify: ___________________________

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Form 6A: Medical History

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Study ID: __ __ __ __ __ __ __ __ __ __
12. Does the subject have any Hematological Disease?

□ No □ Yes □ Unknown
If Yes, does the subject have:

□ No □ Yes □ Unknown
□ No □ Yes □ Unknown
□ No □ Yes □ Unknown

Sickle Cell Disease?
Lymphoma?
Leukemia?

Other, specify: ___________________________
13. Does the subject have any Neurological Disorders?

□ No □ Yes □ Unknown
If Yes, does the subject have:

□ No
□ No
□ No
□ No
□ No
□ No
□ No
□ No

Stoke?
Seizure/Epilepsy?
Intellectual Disability?
Multiple Sclerosis?
Muscular Dystrophy?
Spinal Cord Disease or Injury?
Peripheral Nerve Disease?
Cerebral Palsy?

□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes
□ Yes

□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown
□ Unknown

Other, specify: ___________________________

□ No □ Yes □ Unknown

14. Does the subject have HIV/AIDS?

If Yes, does the subject have a recent (within the last 12 months) CD4 count?

□ No □ Yes □ Unknown
If Yes, what is their most recent:
CD4 count? ____________
Date of CD4 count: __ __ / __ __ / __ __ __ __ (mm/dd/yyyy)
15. Does the subject have an autoimmune disorder?

□ No

□ Yes □ Unknown

If Yes, specify autoimmune disorder: _________________________________

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Form 6A: Medical History

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Study ID: __ __ __ __ __ __ __ __ __ __
16. Does the subject have/has the subject had Cancer?

□ No □ Yes □ Unknown
If Yes, specify Cancer: _____________________
Is the subject on Chemotherapy?

□ No □ Yes □ Unknown

How many medications is the subject taking? (List up to 5)
Specify medications received and date of last dose:
Medication 1: _______________________ Date: __ __ / __ __ / __ __ __ __
Medication 2: _______________________ Date: __ __ / __ __ / __ __ __ __
Medication 3: _______________________ Date: __ __ / __ __ / __ __ __ __
Medication 4: _______________________ Date: __ __ / __ __ / __ __ __ __
Medication 5: _______________________ Date: __ __ / __ __ / __ __ __ __
17. Has the subject had an Organ Transplant?

□ No □ Yes □

Unknown

If Yes, specify organ: __________________________________
18. Has the subject suffered any other medical conditions not mentioned above?

□ No □ Yes □ Unknown
If Yes, specify: _________________________________________________________

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Form 6A: Medical History

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