New Jersey Department of Health

Creutzfeldt-JaKob Disease 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 or Alaska Native	Native Hawaiian or Other Pacific Islander

Black or African American	Asian	Unknown/Other
Ethnicity

Hispanic or Latino	Non-Hispanic or Latino	Unknown
Reporting Physician (Name, Specialty, Address and Telephone No.)

Hospital (Name, Address and Telephone No.)

Date of Diagnosis	Date of Illness Onset	Case Classification

Possible

Probable

Confirmed	CJD Subtypes

Sporadic

Familial

Iatrogenic

Variant
/	/
/	/
Deceased?

Yes No Unknown	Date of Death
/	/
Clinical Features:
Progressive Dementia?	Yes No Unknown
Psychiatric Symptoms?	Yes No Unknown
Ataxia?	Yes No Unknown
Myoclonus?	Yes No Unknown
Akinetic Mutism?	Yes No Unknown
Pyramidal / Extrapyramidal Dysfunction?	Yes No Unknown
Did psychiatric symptoms precede onset of dementia?	Yes No Unknown
Risk Factors:
Did patient have a risk factor for iatrogenic CJD (e.g., history of exposure to potentially contaminated neurosurgical equipment, corneal transplant, dura mater grafts, human-derived growth hormone)?	Yes No Unknown
If yes, please specify risk factor:
Did patient live more than 6 months in Europe in last 10 years?	Yes No Unknown
If yes, when:
Did patient have familial history of dementia?	Yes No Unknown
If yes, please specify:
Laboratory Tests:
CSF examination date:	/	/
Protein:	WBC/mL:
Was CSF tested for presence of protein 14-3-3?	Yes No
If yes, protein 14-3-3 present?	Yes No
Was EEG examination performed:	Yes No
If yes, does it show periodic or pseudoperiodic paroxysms of triphasic or sharp waves (0.5 to 2.0 Hz) against a slow background?	Yes No
If no, specify what was observed:
Was diagnosis confirmed by histopathological examination (brain biopsy or post-mortem examination)?	Yes No
If yes, specify results:
Name and Title of Person Submitting Report

Telephone Number

CDS-8

AUG 12

CDS-9 Creutzfeldt-Jakob Disease Report

Communicable Disease Service, Disease Report, Creutzfeldt-Jakob Disease, Infectious and Zoonotic Diseases, cds-9, cds

EWhite

2012-03-19

NJDOH