Get Maryland Lyme Disease (ld) Case Report Form Cas - Phpa - Ideha Dhmh Md

Completing the Maryland Lyme Disease Case Report Form is essential for effective disease tracking and response. This guide provides step-by-step instructions to assist users in accurately filling out the form online.

Follow the steps to effectively complete the case report form.

1. Click the ‘Get Form’ button to obtain the Maryland Lyme Disease Case Report Form and open it for editing.
2. Enter the patient's information in the specified fields. Include their last name, first name, middle initial, and the date the case was reported to the health department.
3. Provide the patient's contact information by filling in the home and workplace telephone numbers, as well as the NEDSS (National Electronic Disease Surveillance System) number and zip code.
4. Indicate the patient's gender by selecting one of the options: Male, Female, or Unknown, and provide their date of birth in the format mmddyyyy.
5. Fill in the county of residence and note the patient's Hispanic ethnicity and race by checking the applicable boxes.
6. In the 'Physician/Provider Information' section, enter the name, phone number, and fax number of the healthcare provider.
7. Document the laboratory findings. Record the results of the EIA/IFA tests, including specimen collection dates, and whether the assay uses C6 peptide, IgM, or IgG antibodies.
8. Describe exposure and clinical signs and symptoms. Indicate if the healthcare provider diagnosed the patient with Lyme disease, and provide the date of diagnosis and symptom onset.
9. Check the presence of case definition signs and symptoms, including erythema migrans, arthritis, neurological symptoms, and other relevant conditions.
10. Fill in the supplemental information about the patient's pregnancy status, hospitalization, and antibiotics used during the illness.
11. Finalize the form by reviewing all information for accuracy. Once complete, save any changes made, and choose to download, print, or share the form.

Complete and submit the Maryland Lyme Disease Case Report Form online to help in the effective tracking and management of Lyme disease.