We are calling to inform you that _______________________ is a patient of yours and an employee at ____________. He/she has signed a medical release giving us permission to contact you to obtain information about her/his recent illness. This questionnaire will be used to determine if your patient's recent illness could be classified as a pneumonia that may have been caused by exposure to
Legionnaires' disease bacteria (LDB) at the workplace.
- Name of Physician: ________________________________________
Address:___________________________________________________
Phone:_____________________________
- Date of visit(s): (1st)________ (2nd)________ (3rd)________
- What was the patient's
complaint?:_______________________________________________________________
|
Cough?
Short of breath?
History of fever?
|
Yes
Yes
Yes |
No
No
No |
Unknown
Unknown
Unknown |
- Physical Findings: _____________________________________________
____________________________________________________________
Abnormal chest or lung findings: _________________________________
____________________________________________________________
|
Rales?
Dyspnea?
Cyanosis?
|
Yes
Yes
Yes |
No
No
No |
Not examined
Not examined
Not examined |
Temperature ______
Other: __________________________________________________
- Chest x-ray done? Yes No
Findings: _____________________________________________
- Sputum culture? Yes No
Results:______________________________________________
Sputum cultured for Legionella? Yes No
Laboratory:___________________________________________
- Diagnostic testing? Yes No
Type of test (circle all that apply): Urine Antigen Test, Direct Fluorescent Antibody Serology Tests:
Indirect Fluorescent Antibody (IFA) ______
ELISA ________
Laboratory:____________________________________________
- Diagnosis or impression: _____________________________________
|
