STATE DATA BASE NUMBER
DEMOGRAPHIC DATA
PATIENT INFORMATION
Occupation or Contact with Vulnerable Persons
MORBIDITY
DATA
HIV
and
AIDS
TB
and OTHER
MYCOBACT.
Major Site:
Non TB: Atypical (Specify)
Pulmonary
Extrapulmonary
Provider Name
Abnormal Chest X-ray
Date of Report
REPORTING
SOURCE
(REQUIRED)
Facility/Organization (Name and Address)
Provider Telephone No.
NOTE
S: Your local health department may contact you following this initial report to request additional disease-specific information.
To print blank report forms or get more information about reporting, go to http://phpa.dhmh.maryland.gov/Pages/what-to-report.aspx
Unknown
Race:
American Indian or Alaskan Native
Asian
Black or African American
Hawaiian or Pacific Islander
White
Unknown
Other (specify):
Ethnicity: Hispanic or Latino
Not Hispanic or Latino
Check here
if completed
by the
Local Health
Department
Other STI (specify)
HIV Genotype (Re
s
istance)
Primary
Secondary
Early Latent (<1 yr)
Congenital
Other Stage (specify)
Name of Testing Lab
Cervical
Urethral
Rectal
Pharyngeal
Ophthalmia Neonatorum
PID
Other (specify)
Cervical
Urethral
Rectal
Pharyngeal
PID
Other (specify)
Chlamydia Site(s)
Syphilis Symptoms
Lesion
Palmar/Plantar Rash
Condylomata Lata
Neurologic
Other (specify)
Specify STI Lab Test (e.g. RPR Titer, FTA-TPPA, Darkfield, Smear, Culture, NAAT, EIA, VDRL-CSF)
STI Treatment Given (Specify date – drug – dosage below) No Treatment Given
DATE TEST RESULT DATE DRUG DOSAGE
SEXUALLY TRANSMITTED INFECTION
Laboratory Results
HEPATITIS
Health Care Worker
Parent of Daycare Child
Not Employed
Other (Specify):
Workplace, School, Child Care Facility, Etc. (Include Name, Address, Zipcode)
Patient’s Name (Last) (First) (M.I.)
Date of Birth
Age
Sex at Birth
Male
Female
Patient’s Address City State Zip
County of Residence Home Telephone Cellphone Work Telephone
HIV Diagnostic (Specify)
CD4+ T-cells
HIV Viral Load
HIV Lab Tests
Date
Result
Risk Exposure
MARYLAND CONFIDENTIAL MORBIDITY REPORT (DHMH 1140)
(For use by physicians and other health care providers, but not laboratories. Laboratories should use forms DHMH 1281 & DHMH 4492.)
SEND TO YOUR LOCAL HEALTH DEPARTMENT
DHMH 1140
Revised 03/2017
HAV Antibody Total
HAV Antibody IgM
HBV surface Antigen
HBV e Antigen
HBV core Antibody Total
HBV core Antibody IgM
HBV surface Antibody
HBV DNA
HCV Antibody RIBA
HCV RNA (e.g. by PCR)
HCV Antibody ELISA
HCV ELISA s/co Ratio
HCV Genotype
ALT (SGPT) Level
ALT–Lab Normal Range
AST (SGOT) Level
AST–Lab Normal Range
Name of Lab
TO
DATE
DATE
DATE
TO
AFB Smear
Culture
Disease or Condition Date of Onset Patient Notified of this Condition Pertinent Clinical Information/Comments
Suspected Source
Additional Lab Results
(Specimen – Test – Result – Date – Name
of Lab) Please attach copies of lab reports whenever possible.
Patient Died of This Illness
Yes No
Da
te
Condition Acquired in Maryland
Patient Pregnant
Yes No
If yes, Due date (mm
/dd/yyyy)
Unknown
Weeks Pregnant
Not applicable
Yes
No
If no, Interstate
International
Yes
No
Unknown
Symptoms:
Cough >3 Weeks
Hemoptysis
Fever
Weight Loss
Fatigue
POS
NEG
POS
NEG
AFB Smear
Culture
Sex with Male
Sex with Female
Sex Partner has
HIV or AIDS
Sex Partner Injects Drugs
Sex Partner is Male that
has Sex with Males
Injection Drug Use
Perinatal Exposure of
Newborn
Other Exposure (specify)
Did you provide treatment for any of this patient's partners? (Check all that apply)
Yes, I gave medication for __ (#) partner(s)
Complete for HIV/AIDS or STI
Current Gender
Male
Female
M
to F Transgender
F to M Transgender
Other
(Select all that apply)
Syphilis Stage
Gonorrhea Site(s)
Site:
Yes, I wrote a prescription for __(#) partner(s)
TST
Yes, I saw the sex partner(s) in my office
Tuberculosis (Suspect or Confirmed)
POS QFT
NEG
mm
QFT
Food Service Worker
Daycare
POS NEG DATE
POS NEG DATE
Patient Hospitalized Yes No
Date Hospital
