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Appendix II:B-5. Physician Survey Questionnaire - Legionellosis

Appendix II:B-5. Physician Survey Questionnaire - Legionellosis
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.
  1. Name of Physician: ________________________________________

    Address:___________________________________________________

    Phone:_____________________________

  2. Date of visit(s): (1st)________ (2nd)________ (3rd)________

  3. What was the patient's complaint?:_______________________________________________________________
    Cough?
    Short of breath?
    History of fever?
Yes
Yes
Yes
No
No
No
Unknown
Unknown
Unknown

  1. Physical Findings: _____________________________________________

    ____________________________________________________________

    Abnormal chest or lung findings: _________________________________

    ____________________________________________________________
    Rales?
    Dyspnea?
    Cyanosis?
Yes
Yes
Yes
No
No
No
Not examined
Not examined
Not examined

Temperature ______

Other: __________________________________________________
  1. Chest x-ray done?     Yes       No

    Findings: _____________________________________________

  2. Sputum culture?         Yes       No        

    Results:______________________________________________

    Sputum cultured for Legionella?     Yes       No

    Laboratory:___________________________________________

  3. 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:____________________________________________

  4. Diagnosis or impression: _____________________________________

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