VIRUS DATA FORMAT QUESTIONNAIRE 071381             PATIENT NUMBER [p9a1      ]
PATIENT NAME [Pa2                             ]  Q SENT [      ]  Q RET [ ]
LENGTH/ILL [                          ]  HOSP [                              ]
FINAL DISPOSITION [                                                          ]
CLINICAL:  [ ] CONJUNC  [ ] PHOTOPHOBIA  [ ] POOR APP  [ ] DIZZY  [ ] WEAKNESS
 [ ] TESTIC PAIN/SWELL  [ ] PNEUMONIA  [ ] PLEURISY  [ ] MYOCARD  [ ] PERICARD
 [ ] HEPATOMEG  [ ] SPLENOMEG  [ ] ABN EEG  [ ] CONSCIOUS CHG  [ ] MENTATN CHG
 [ ] + KERNIG  [ ] + BRUD  [ ] SEIZURE  [ ] LETHAR  [ ] MALAISE  [ ] IRRITABLE
 [               ]  [               ]  [               ]  [                  ]
ERUPTIONS:  [ ] ORAL  [             ] TYPE  [ ] GENITAL  [              ] TYPE
EXANTHEM:  [                      ] TYPE  [                         ] LOCATION
ENANTHEM:  [                      ] TYPE  [                         ] LOCATION
LAB:  BLD:  [      ] (K) WBC  [      ] (K) PLTC  DIFF:  [    ] % SEGS
 [   ] % BANDS  [   ] % LYMPHS  [      ] ATYP  [    ] PLT    CSF:  [    ] RBC
 [    ] WBC  [               ] DOM TYPE  [    ] (mg%) PROT  [    ] (mg%) SUGAR
 [    ] (mg%) BLD SUGAR  [                                                   ]
EPIDEMIOLOGY:  [ ] CONTACTS  [                           ] RELATION  [   ] SEX
 [            ] AGE  [                                ] SYMP  [ ] COMM OUTBK
 [                    ] OUT/STATE  [                                ] ILL/PREG
IMMUNIZATIONS: [                        ] OPV  [      ] MEASLS  [      ] MUMPS
 [      ] RUBELLA  [      ] INFLUENZA  [                                     ]
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