Disease or suspected disease being notified:
Date of onset of illness (approximately):
Laboratory tests done or ordered (if any):
Results of laboratory tests (if available):
If the disease or suspected disease is HIV or AIDS, whether or not there is laboratory evidence of newly acquired HIV infection (if known):
If the disease or suspected disease is HIV, AIDS, or syphilis, the date and place of last negative laboratory test (if known):
Has the patient been hospitalised? Yes/No
If the patient has been hospitalised, the name of the hospital and date of the admission:
If the disease or suspected disease is HIV, AIDS, or syphilis, has the patient been referred to specialist care? Yes/No
Any other information relevant to the risk of the patient having or transmitting the disease (for example, vaccine history, sexual behaviour or activity, or sex of partner or partners, if known):