LEGIONELLA - World Health Organization

Clinical details
Date of onset / / Date of admission to hospital / /
Hospital name:
Ward:
Consultant’s name:
Main clinical features of current illness:
Immunosuppression: ❑ Yes ❑ No
Cause:
Current illness outcome:
Laboratory diagnosis for this episode of illness
Urinary antigen: ❑ Yes ❑ No
Date of specimen / / Result: ❑ Positive ❑ Negative
Culture: ❑ Yes ❑ No
Date of specimen / / Result: ❑ Positive ❑ Negative
Serology: ❑ Yes ❑ No
Date of specimen / / Result: ❑ Positive ❑ Negative
Organism: Serogroup:
Risk factors for patient within incubation period
(approximately 2 weeks prior to onset of illness)
Dates: / / to / /
Hospital inpatient: ❑ Yes ❑ No Name of hospital:
Hospital outpatient: ❑ Yes ❑ No Name of hospital:
Dental treatment: ❑ Yes ❑ No Name of dentist:
Address:
00 LEGIONELLA AND THE PREVENTION OF LEGIONELLOSIS