Pediatric severe influenza illness form ( 18 years old - IDEHA 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the State case ID and CDC case ID at the top of the form.
3. Indicate any complications or outcomes applicable to the patient by checking the relevant boxes.
4. Provide your contact information, including first name, last name, title, institution, city, state, phone, fax, and email.
5. Complete the patient demographics section with details such as name or initials, date of birth, gender, race, ethnicity, and place of residence.
6. Document the illness course by entering dates for illness onset and fever onset.
7. Check all symptoms and signs experienced by the patient during their illness.
8. Fill out medical care details regarding evaluations and treatments received by the patient.
9. Complete sections on existing medical conditions and medication history as applicable.
10. Finally, review all entries for accuracy before submitting your completed form.

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