VIRUS DATA GENERAL FORMAT  071381                 PATIENT NUMBER [p9s1       ]                                                      
PATIENT NAME [Ps2                             ]  AGE [s3 ] yr  [s4  ] SEX [s5]                                                      
 ADDRESS [                            ]  CITY [                 ]   STATE [  ]                                                      
PHYSICIAN NAME [H                                               ]  COUNTY [  ]                                                      
 ADDRESS [                            ]  CITY [                  ]  STATE [  ]                                                      
CLINICAL DATA:  ONSET DATE [9D    ]  [                          ]  ZIP [9    ]                                                      
 [          ] FEVER  [  ] HEADACHE  [ ] MYALGIA  [ ] LYMPHAD  [ ] MYOPERICARD                                                       
 [ ] PLEURODYN  [ ] ORGANOMEG  [ ] BRONCH  [ ] PNEUMON  [ ] INFLU  [ ] ARD                                                          
 [ ] COMM COLD [ ] SORE THROAT  [ ] NAS DISCH  [ ]  [  ] COUGH  [ ] GASTROENT                                                       
 [ ] NAUSEA  [ ] VOMIT  [ ] DIARR  [ ] ABD PAIN  [ ] JAUNDICE  [ ] PARALYSIS                                                        
 [ ] ENCEPH  [ ] MENING  [ ] NECK STIFF  [ ] CONVULS  [                      ]                                                      
EXANTHEM: [ ] HERPES  [ ] RUBELLA  [ ] MEASLES  [ ] ENTERO  [ ] RICKETTSIAL                                                         
 [ ] ORAL LESIONS  [ ] OTHER  [                                              ]                                                      
OTHER: [                                                                     ]                                                      
 [                                                                           ]                                                      
 [                                                                           ]                                                      
SPECIMEN#  SPEC TYPE  DATE COLL  DATE RECD  TEST REQUEST          OUTCOME                                                           
 [S    ]  [         ]  [9D    ]   [9D    ]  [                  ]  [          ]                                                      
 [S    ]  [         ]  [9D    ]   [9D    ]  [                  ]  [          ]                                                      
 [S    ]  [         ]  [9D    ]   [9D    ]  [                  ]  [          ]                                                      
 [S    ]  [         ]  [9D    ]   [9D    ]  [                  ]  [          ]                                                      
 [S    ]  [         ]  [9D    ]   [9D    ]  [                  ]  [          ]                                                      
 [S    ]  [         ]  [9D    ]   [9D    ]  [                  ]  [          ]                                                      
 [                                                                    ]  [ ]                                                        
