Date Entered:
* must provide value
Today M-D-Y
Provider's Name:
* must provide value
Primary Phone Number:
* must provide value
###-###-####
Email address
* must provide value
Provide a valid email address, as official correspondence will be sent to this location.
Alternate/After-Hours Phone Number:
* must provide value
###-###-####
Patient's First Name:
* must provide value
Patient's Last Name:
* must provide value
Patient's Date of Birth:
* must provide value
Today M-D-Y MM-DD-YYYY
Patient's Age (in years):
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Calculated field
Patient's Gender:
* must provide value
Female Male Unknown
Patient's Race:
* must provide value
White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Other Unknown
If patient's race is other , please specify:
Patient's Ethnicity:
* must provide value
Hispanic or Latino Not Hispanic or Latino Unknown
Patient's Street Address of Residence 1:
* must provide value
123 Main St
Patient's Street Address of Residence 2:
P.O. Box or Long-term Care Facility, Correctional Facility, or Shelter Name
Patient's City of Residence:
* must provide value
Patient's State of Residence:
* must provide value
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Johnston Atoll Marshall Islands Northern Mariana Islands Palau Midway Islands Puerto Rico U.S. Minor Outlying Islands Navassa Island Virgin Islands of the U.S. Wake Island Baker Island Howland Island Jarvis Island Kingman Reef Palmyra Atoll
Patient's County of Residence:
* must provide value
Autauga County Baldwin County Barbour County Bibb County Blount County Bullock County Butler County Calhoun County Chambers County Cherokee County Chilton County Choctaw County Clarke County Clay County Cleburne County Coffee County Colbert County Conecuh County Coosa County Covington County Crenshaw County Cullman County Dale County Dallas County De Kalb County Elmore County Escambia County Etowah County Fayette County Franklin County Geneva County Greene County Hale County Henry County Houston County Jackson County Jefferson County Lamar County Lauderdale County Lawrence County Lee County Limestone County Lowndes County Macon County Madison County Marengo County Marion County Marshall County Mobile County Monroe County Montgomery County Morgan County Perry County Pickens County Pike County Randolph County Russell County Saint Clair County Shelby County Sumter County Talladega County Tallapoosa County Tuscaloosa County Walker County Washington County Wilcox County Winston County
Complete if Alabama resident.
Patient's Zip Code of Residence:
* must provide value
##### or #####-####
Patient's Phone Number:
* must provide value
###-###-####
Is ______ associated with a correctional facility?
* must provide value
Yes
No
Unknown
If yes , provide name of correctional facility:
* must provide value
Is ______ a healthcare worker in the United States?
* must provide value
Yes
No
Unknown
Please complete the Clinical Presentation and Epidemiologic Risk Factors sections in their entirety,
even if the answer is unknown. Otherwise, testing may be denied.
Did ______ experience any symptoms during his/her illness?
* must provide value
Yes
No
Unknown
Did ______ have a new onset of a clinically compatible rash?
* must provide value
Yes
No
Unknown
The characteristic rash associated with monkeypox lesions involves the following: deep-seated and well-circumscribed lesions, often with central umbilication; and lesion progression through specific sequential stages: macules, papules, vesicles, pustules, and scabs.
Did ______ have other symptoms causing clinical suspicion for monkeypox?
* must provide value
Yes
No
Unknown
If other symptom, please specify:
* must provide value
When did ______ start feeling ill?
* must provide value
Today M-D-Y
Was ______ hospitalized for this illness?
* must provide value
Yes
No
Unknown
Please provide the name of hospital:
* must provide value
Please specify the date of admission:
* must provide value
Today M-D-Y
Did ______ have another diagnosis/etiology for their illness?
* must provide value
Yes
No
Did Not Assess
Unknown
Please specify the alternative diagnosis/etiology:
Please specify which of the following etiologies/diagnoses were ruled out:
Herpes simplex virus
Syphilis
Chancroid
Lymphogranuloma venereum
Granuloma Inguinale
Varicella
Molluscum contagiosum
Other pox viruses
Disseminated Fungal Infections
Disseminated Gonococcal Infection
Gonorrhea
Chlamydia
Recurrent aphthous stomatitis
Behcet's Disease
Trauma
Squamous cell carcinoma
Drug-induced
Other
Does ______ have any immunocompromising conditions or immunosuppressive medications?
* must provide value
Yes
No
Unknown
If yes , please specify the immunocompromising conditions and/or medications:
* must provide value
The next few questions will ask about exposures ______ may have had in the 21 days prior to illness onset. The time period is indicated by the earliest and latest dates of potential exposure listed below.
Name of the country where ______ lived or traveled to:
* must provide value
Earliest Date of Potential Exposure:
* must provide value
Today M-D-Y
Latest Date of Potential Exposure:
* must provide value
Today M-D-Y
Number of days between last exposure and illness onset
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Does ______ agree for CDC to use anonymized photos of their rash/lesions?
* must provide value
Yes
No
Did not ask
Unknown
If yes, please ask ______ to sign the attached photo release form from CDC. Please upload the signed form below along with any additional documents you may have.
To help determine testing needs, provide the following information in addition to the information entered on this consultation form: ✅ History and physical ✅ Images (*requested to assess rash ) If the documents are not uploaded with this submission, someone from ADPH will be in touch with the reporter shortly to collect the additional information. How many would you like to upload?
* must provide value
0 1 2 3 4 5
The clinical and epidemiological evidence provided in this form will be reviewed by ADPH Medical Officer to determine whether ______ needs to be tested for monkeypox.
Based on the clinical and epidemiologic evidence, ______ does not meet criteria for monkeypox testing. Please consider testing ______ for other potential causes of illness.
Additional Information/comments:
Was the consultation form reviewed by a medical officer?
Yes
No
Unknown
Is ______ approved for testing?
Yes
No
Needs more information
What additional information should be requested from the provider?
* must provide value
Initials of the medical officer who reviewed the consultation form:
Date when the consultation form was reviewed:
Today M-D-Y
Was ______ 's specimen positive for non-variola orthopoxvirus?
Yes
No
Inconclusive
Pending
Select "Pending" once testing is approved. Then, update once results have been received.
(from initial consult with the call center)
Please enter the following State Case ID into the box on the right: AL-______ -______ -______
Suspect
Probable
Confirmed
Person Under Investigation
Not a Case
Reviewed by ID&O
Gathering additional information
Sent to physician for review
Sent to District
Complete
Other
If Other , please specify:
Misti Denmark
Jennifer Owes
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HIDDEN - Record ID with Leading Zeros
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