VIRUS DATA GENERAL FORMAT  022682                 PATIENT NUMBER [p9s1a1     ]
PATIENT NAME [Ps2Ra2                          ]  AGE [s3a3l2] yr  [s4a49l4] SEX [s5a5l1]
 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: [                                                                     ]
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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    ]  [                  ]  [          ]
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