LEGIONELLA - World Health Organization

Appendix 2 Example
of a 2-week follow-up form
This appendix provides an example from the United Kingdom of a form for local use, for
collecting a 2-week history before onset of Legionnaires’ disease.
Legionnaires’ disease — case follow-up
Date of interview / / Name of interviewer
Personal details of case
Family name
First name
Post held
Tel. no:
Age DOB / / Sex: ❑ Male ❑ Female
Home address
Home telephone: ( )
GP name:
GP address:
GP telephone: ( )
Patient’s occupation:
Workplace address:
Workplace telephone: ( )
Smoker: ❑ Yes ❑ No Average number per day:
Other risk factors:
Family contacts at risk from disease: ❑ Yes ❑ No
Name:
LEGIONELLA AND THE PREVENTION OF LEGIONELLOSIS
Postcode
Postcode:
Postcode: