Form 0920-1305 Chronic Q Fever - Enhanced Surveillance Follow-up Instru

Form Approved
OMB Control No.:0920-1305
Expiration date: xx/xx/xxxx

QID:________
Chronic Q Fever - Enhanced Surveillance Follow-up Instrument
Survey instrument for clinician follow-up at 6, 12, 18, and 24 months after initial consultation request.
1. Date of follow-up: __/__/____ (DD/MM/YYYY)
2. Is the patient still serologically monitored for Q fever? Yes No Unknown (if yes go to 2a if
no/unknown skip to 2b).
a. How frequently are Q fever serologies collected from the patient? Approximately every
_____ months
b. What was the date of the most recent titer values collected? __/__/___ (DD/MM/YYYY)
i. What were these titers? Ph1 IgG ________; Ph2 IgG __________
c. Were other titers collected? Yes No Unknown (If yes, go to 2ci, if no/unknown,
go to 3.)
i. What was the date that these titers were collected? __/__/____ (DD/MM/YYYY)
ii. What were these titers? Ph1 IgG ________; Ph2 IgG __________
d. Were other titers collected? Yes No Unknown (If yes, go to 2di, if no/unknown,
go to 3.)
i. What was the date that these titers were collected? __/__/____ (DD/MM/YYYY)
ii. What were these titers? Ph1 IgG ________; Ph2 IgG __________
3. Has the patient had a PCR test since the last follow-up? Yes No Unknown (if yes go to 3a
if no/unknown skip to 4).
a. What was the date of the most recent PCR test? __/__/___ (DD/MM/YYYY)
i. What were the result? Detected Not Detected Unknown
4. Has the patient completed antibiotic therapy? Yes No Unknown (if yes/no go to 3a, if
unknown go to 4).
a. Which antibiotics did the patient receive? Doxycycline Hydroxychloroquine Other
________
b. How long has the patient on antibiotic therapy? ______(months)
c. What was the dose and interval of these medications? _______ (dose, interval)
d. Was the patient taken off any antibiotic during treatment due to side effects? Yes
No Unknown (If ‘no’ or ‘unknown’, skip to question 2e)
e. If yes which medication (s) were stopped? Doxycycline Hydroxychloroquine Other
________
f. What were the side effects? nausea vomiting fatigue photosensitivity
 Other:______  Unknown
g. Did the patient develop any of the following complications from antibiotic therapy
(select all that apply)?
 Retinal damage
QT prolongation
irreversible skin pigmentation
Public reporting burden of this collection of information is estimated to 10 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
Reports Clearance Officer, 1600 Clifton Road NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-1305

QID:________
Other _______________

 None

5. Have the patient’s symptoms changed since the initial consult?
 Yes, symptoms have fully resolved (go to question 5)
 Yes, symptoms improved but persist (go to question 5)
 Yes, symptoms have worsened (go to question 5)
 No (go to question 6)
6. Please describe any new or worsening symptoms: _____________ (free text)
7. Did the patient die from complications of chronic Q fever? Yes No Unknown
(If ‘no’ or ‘unknown’, go to question 7.)
a. Date of death: __/__/____ (DD/MM/YYYY)
b. Cause of death per death certificate: ________________________________(free text)
8. Was the patient hospitalized from complications of chronic Q fever? Yes No Unknown
(If ‘no’ or ‘unknown’, go to question 8.)
a. Date of hospitalization: __/__/____ (DD/MM/YYYY)
b. Duration of hospitalization: __________ (days)
c. Cause of hospitalization and brief summary of hospital course: ____________ (free text)
9. Was the patient diagnosed with lymphoma since the last consult? Yes No Unknown
a. If yes, please describe: ___________ (free text)
10. Did the patient become pregnant since the last consult? Yes No Unknown If ‘no’ or
‘unknown’, go to question 17.)
11. What treatment was provided during the patient’s pregnancy? ______________ (free text)
12. What was the outcome of the patient’s pregnancy?
 Term delivery (go to question 13)
 Preterm delivery (go to question 13)
 Currently pregnant (go to question 15)
 Stillbirth
 Miscarriage
 Other loss of pregnancy
13. Were there any complications during delivery? Yes No Unknown
a. If yes, please describe: __________ free text
14. Were there any complications after delivery for the baby or patient? Yes No Unknown
a. If yes, please describe: __________ free text
15. Were there any complications during pregnancy? Yes No Unknown
a. If yes, please describe: __________ free text
16. Were any of the following studies performed? Choose all that apply:
 Echocardiogram (go to question 9)

QID:________
 MRI (go to question 10)
 CT Scan (go to question 11)
 PET Scan (go to question 12)
17. Details of echocardiography:
a. What was the date of the exam: __/__/____ (DD/MM/YYYY)
b. Was the exam transthoracic or transesophageal?
 Transthoracic
 Transesophageal
c. Please provide a brief summary of findings: ____________ (free text)
18. Details of MRI:
a. What was the date of the exam: __/__/____ (DD/MM/YYYY)
b. What was the anatomic location of the scan: ________ (free text)
c. Please provide a brief summary of findings: ____________ (free text)
19. Details of CT Scan:
a. What was the date of the exam: __/__/____ (DD/MM/YYYY)
b. What was the anatomic location of the scan: ________ (free text)
c. Please provide a brief summary of findings: ____________ (free text)
20. Details of PET Scan:
a. What was the date of the exam: __/__/____ (DD/MM/YYYY)
b. What was the anatomic location of the scan: ________ (free text)
c. Please provide a brief summary of findings: ____________ (free text)