Brucellosis Case Report Form - ideha dhmh maryland 2026

1. Click ‘Get Form’ to open the Brucellosis Case Report Form in the editor.
2. Begin by filling out the Patient Identifier Information section. Enter the patient's full name, phone number, medical chart number, address, state, zip code, and hospital name.
3. Proceed to the Patient & Physician Information section. Input the State Case ID, investigator's name, date reported, physician's name and contact information.
4. Complete the Demographics section by providing details such as state of residence, county of residence, age, sex, pregnancy status, country of birth, ethnicity, race, and occupation.
5. In the Clinical Information and Treatment section, indicate disease presentation and symptoms. Specify if hospitalization occurred and provide treatment details including medication names and dosages.
6. Fill out the Risk Factors section by selecting any relevant travel history or animal contact. Indicate if unpasteurized dairy was consumed and if there are links to confirmed cases.
7. Finally, complete the Laboratory Data section for each lab processing samples. Ensure all required fields are filled accurately before submitting your form.

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