Tickborne Disease Case Report Form (PDF) - health state mn 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'MEDSS ID' and select the appropriate tick-borne disease from the options provided, such as Lyme disease or Anaplasmosis.
3. Complete the 'DEMOGRAPHICS' section with the patient's name, date of birth, age, sex, and contact information. Ensure all fields are filled accurately.
4. In the 'PROVIDER' section, enter the provider's name and role. If applicable, include hospitalization details in the 'HOSPITAL / CLINIC INFORMATION' section.
5. Proceed to fill out the 'HEALTH HISTORY' and 'CLINICAL INFORMATION' sections, providing details on symptoms and any relevant medical history.
6. Finally, complete the 'TREATMENT AND DIAGNOSTIC TESTING' section by documenting any treatments administered and lab results.

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