New Jersey Department of Health

hemolytic uremic syndrome (post-diarrheal) report	Date

CDRS ID No.

Name (Last)	(First)	(MI)

Sex

Date of Birth (Age)

Street Address

County

City	State	Zip Code

Telephone Number

Race

White	American Indian	Unknown/Other

Black	Asian	Ethnicity

Hispanic	Unknown

Non-Hispanic
Reporting Physician (Name, Address and Telephone No.)

Hospital (Name, Address and Telephone No.)

Date of Diagnosis	Onset Date of Illness	Hospitalized-Date of Admission:	Deceased?

Yes

No

Unknown	Case Status

Possible

Probable

Confirmed
/	/
/	/
/	/
Clinical Manifestations:
1.	Anemia:	Yes No
2.	Renal injury:	Yes No
3.	History of acute gastrointestinal illness within the last 3 weeks (ask

specifically about E. coli O157:H7 or Shigella dysenteriae infections):	Yes No
If Yes, specify:
Laboratory Test Results (Attach copy of lab reports)
1.	Hemoglobine:
2.	Microangiopathic changes (schistocytes, burr cells

or helmet cells) on peripheral blood smear present::	Yes No
3.	Creatinine:	BUN:
4.	Hematuria:	Yes No	Proteinuria:	Yes No
5.	Stool bacteriological examination:	Not done
Comments:

Name and Title of Person Submitting Report

Telephone Number

CDS-15

AUG 12

CDS-15, Hemolytic Uremic Syndrome (Postdiarrheal) Report

cds-15, hemolytic uremic syndrome, post-diarrheal, report, communicable disease service, IZDP, infectious and zoonotic disease program

EWhite

2012-03-19

NJDOH