Form 0920-1170 Case Questionnaire

Form Approved

OMB No. 0920-1170

Expires 03/31/2019

CANINE LEPTOSPIROSIS SURVEILLANCE

CASE QUESTIONNAIRE

Study Case ID:

Clinic/Shelter Patient Record ID:

Place pre-printed label here

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

Clinic / Shelter Name: _________________________________________ Facility type:

Vet / Staff Name: _____________________________________________ ☐ Clinic ☐ Shelter

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	Specimens collected: Date: _____/_____/____ ☐ Serum ☐ Blood ☐ Urine – cystocentesis ☐ Urine - free catch ☐ Kidney tissue 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 If other lepto tests were done, please record results: IDEXX lepto snap: ☐ Pos ☐ Neg ☐ Invalid Zoetis WITNESS lepto: ☐ Pos ☐ Neg ☐ Invalid Other Lab Tests Done: ☐ Hematology ☐ Biochemistry ☐ Urinalysis Attach a copy of the lab report OR fill in lab values below: 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 = ____________
Hospitalization status and 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, # of days prescribed: ___________ ; Name of antibiotic(s):____________________________________
Send a copy of this form by fax to 404-471-8642 OR by email to ygn3@cdc.gov OR with monthly shipments to CDC. Thank you!

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