MARYLAND CONFIDENTIAL MORBIDITY REPORT (DHMH …
MARYLAND CONFIDENTIAL MORBIDITY REPORT (DHMH 1140)
(For use by physicians and other health care providers, but not laboratories. Laboratories should use forms DHMH 1281 & DHMH 4492.)
SEND TO YOUR LOCAL HEALTH DEPARTMENT
STATE DATA BASE NUMBER
Patient's Name (Last)
(First)
(M.I.)
Date of Birth Age Sex at Birth
Male Female
DEMOGRAPHIC DATA PATIENT INFORMATION
Patient's Address
City
County of Residence
Home Telephone
Cellphone
Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown Occupation or Contact with Vulnerable Persons Food Service Worker
Health Care Worker Daycare
Parent of Daycare Child
Workplace, School, Child Care Facility, Etc. (Include Name, Address, Zipcode)
State Zip Work Telephone
Not Employed Other (Specify):
Current Gender
Male Female
M to F Transgender
F to M Transgender Other
Race: American Indian or Alaskan Native
Asian
Black or African American Hawaiian or Pacific Islander White Unknown Other (specify):
Disease or Condition
Patient Hospitalized Yes
Date
Hospital
Date of Onset Patient Notified of this Condition Yes No
No
Patient Died of This Illness
Yes No Date
Pertinent Clinical Information/Comments
MORBIDITY DATA
Patient Pregnant Yes No Unknown
If yes, Due date (mm/dd/yyyy) Weeks Pregnant
Condition Acquired in Maryland
Not applicable Yes
No
Unknown
If no, Interstate International
Suspected Source
Additional Lab Results (Specimen ? Test ? Result ? Date ? Name
of Lab) Please attach copies of lab reports whenever possible.
HEPATITIS
Laboratory Results POS NEG
HAV Antibody Total HAV Antibody IgM HBV surface Antigen HBV e Antigen HBV core Antibody Total HBV core Antibody IgM
DATE
POS NEG HBV surface Antibody
HBV DNA
HCV Antibody RIBA
HCV RNA (e.g. by PCR)
HCV Antibody ELISA HCV ELISA s/co Ratio
DATE
HCV Genotype ALT (SGPT) Level ALT?Lab Normal Range AST (SGOT) Level AST?Lab Normal Range Name of Lab
DATE DATE TO DATE
TO
HIV and AIDS
HIV Lab Tests
HIV Diagnostic (Specify)
CD4+ T-cells
HIV Viral Load
HIV Genotype (Resistance)
Syphilis Stage Primary Secondary Early Latent ( ................
................
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