Case Questionnaire - Dog Owner

Form Approved

OMB No. 0920-xxxx

Expires xx/xx/xxxx

CANINE LEPTOSPIROSIS SURVEILLANCE

CASE QUESTIONNAIRE

Study Case ID:

Place pre-printed label here

Clinic/Shelter ID:

Date: _____ /_____ /_____ (MM, DD, YY)

Clinic / Shelter Name: _________________________ Facility type: ☐ Clinic ☐ Shelter Vet / Staff Name: _____________

Section 1. General Information
Owner Information Does the dog have an owner? ☐ Yes ☐ No (stray) ☐ Unknown If yes, Last Name: ____________________ First Name: _________________________ Address of owner or stray pick-up location: Street Address (or major intersection): ________________________________________________________________ City: _______________________________ Municipality: ____________________________ Zip Code: ___________ Signalment Dog’s Name: _________________ Age: _____ ☐ Yr ☐ Mo Sex: ☐ Male ☐ Female Spayed/Neutered? ☐Yes ☐ No Breed: ☐ Mix ☐ Purebred Breed (if known): __________________________ __ Weight: _________ ☐ lbs ☐ kg
Section 2. Risk Factors and Exposures
Check all that apply (unless otherwise indicated): Is the dog a: ☐ Pet ☐ Neighborhood dog ☐ Watchdog ☐ Hunting dog ☐ Herding dog ☐ Other: _______________ Where does the dog spend his/her time (pick one)? ☐ Mostly indoors ☐ Mostly outdoors ☐ 50% indoors / 50% outdoors ☐ Always outdoors When outdoors, in what area does the dog spend time (pick one)? ☐ Fenced yard ☐ Allowed to roam ☐ Both areas Does the dog drink water from: ☐ Inside house ☐ Outside house ☐ Puddles ☐ Lake/pond ☐ River/stream ☐ Other: __________________ Does the dog eat food: ☐ Inside house ☐ Outside house ☐ Other: ___________________________________ Does the dog sleep: ☐ Inside house ☐ Outside house ☐ Other: ___________________________________ Does the dog have contact with: ☐ Owned dogs ☐ Stray dogs ☐ Rodents ☐ Livestock: __________ ☐ Wildlife: __________ ☐Other: ___________ In the last 30 days, has the dog swum in: ☐ River/stream ☐ Lake/pond ☐ Puddle In the last 30 days, has the dog traveled outside of the city of residence? ☐ Yes, where? _________________________________ ☐ No ☐ Unknown In the last 30 days, has the dog had contact with a sick dog diagnosed with leptospirosis? ☐ Yes ☐ No ☐ Unknown Have rodents or evidence of rodents (feces, eaten food stores, holes) been seen in the house? ☐ Yes ☐ No ☐ Unknown Have rodents or evidence of rodents been seen in other areas where the dog lives/goes? ☐ Yes, where? _________________________________ ☐ No ☐ Unknown Has the dog had a previous diagnosis of leptospirosis? ☐ Yes, date: ____ /____ /____ (MM, DD, YY) ☐ No ☐ Unknown Has the dog been vaccinated against leptospirosis? ☐ Yes ☐ No ☐ Unknown If yes, , Date of vaccination: ____ /____ /____ (MM, DD, YY) Vaccine Name:___________________________________
Section 3. Clinical and Laboratory Information
Signs and Symptoms Date of symptom onset: ____ /____ /____ (MM, DD, YY) What clinical signs have occurred since symptom onset? Provide one response for each line. Fever ☐ Yes, Temp: ________°C ☐ No ☐ Unk Lethargy/weakness ☐ Yes ☐ No ☐ Unk Inappetence/anorexia ☐ Yes ☐ No ☐ Unk Vomiting ☐ Yes ☐ No ☐ Unk Diarrhea ☐ Yes ☐ No ☐ Unk Abdominal pain ☐ Yes ☐ No ☐ Unk Muscle/joint tenderness ☐ Yes ☐ No ☐ Unk Conjunctivitis/red eyes ☐ Yes ☐ No ☐ Unk Icterus/yellow skin or eyes ☐ Yes ☐ No ☐ Unk Cough ☐ Yes ☐ No ☐ Unk Tachypnea/dyspnea ☐ Yes ☐ No ☐ Unk Oliguria/anuria ☐ Yes ☐ No ☐ Unk Polyuria/polydipsia ☐ Yes ☐ No ☐ Unk Renal failure/insufficiency ☐ Yes ☐ No ☐ Unk Liver failure/elevated enzymes ☐ Yes ☐ No ☐ Unk Uveitis ☐ Yes ☐ No ☐ Unk Altered mentation ☐ Yes ☐ No ☐ Unk Abortion ☐ Yes ☐ No ☐ Unk Pulmonary hemorrhage ☐ Yes ☐ No ☐ Unk Other bleeding ☐ Yes, _________________ ☐ No Other signs/symptoms ☐ Yes, _________________ ☐ No	Laboratory Results Lepto Rapid Test 1: Date: ____/____/____ ☐ Negative ☐ Positive Perform test #2 if the first lepto rapid test was negative and blood was collected <7 days after symptom onset. Lepto Rapid Test 2: Date: ____/____/____ ☐ Negative ☐ Positive Other lab tests done: ☐ Hematology ☐ Biochemistry ☐ Urinalysis PLEASE ATTACH A COPY OF THE LAB REPORT Specimens collected: Date: _____/_____/____ ☐ Serum ☐ Blood ☐ Urine – cystocentesis ☐ Urine - free catch ☐ Kidney tissue IDEXX Lepto snap: ☐ Pos ☐ Neg ☐ N/A Lab Values: Creatinine: ☐ Norm ☐ High ☐ Low BUN: ☐ Norm ☐ High ☐ Low ALT: ☐ Norm ☐ High ☐ Low AST: ☐ Norm ☐ High ☐ Low ALP: ☐ Norm ☐ High ☐ Low Bilirubin: ☐ Norm ☐ High ☐ Low Albumin: ☐ Norm ☐ High ☐ Low CPK: ☐ Norm ☐ High ☐ Low K: ☐ Norm ☐ High ☐ Low HCT = __________% Platelet: ☐ Norm ☐ High ☐ Low WBC: ☐ Norm ☐ High ☐ Low Neutrophil: ☐ Norm ☐ High ☐ Low Lymphocyte: ☐ Norm ☐ High ☐ Low Urine specific gravity = ____________
Outcome Was the dog hospitalized? ☐ Yes, # of days: ___________ ☐ No Outcome: ☐ Discharged ☐ Died ☐ Unknown If died, was it due to: ☐ Euthanasia ☐ Unassisted/natural death Were antibiotics prescribed? ☐ Yes ☐ No If yes, no. of days prescribed: ___________ ; Name of antibiotic(s):_____________________________________________
Send a copy of this form by fax to 404-471-8642 OR by email to study coordinators OR with monthly shipments to CDC. Thank you!

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74,  Atlanta, Georgia 30333; ATTN:  PRA (0920-xxxx).