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Fields
Confidential Morbidity Report Form
Provider Information
Physician Name
First Name
Last Name
Physician Phone Number
Facility Phone
Facility Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Patient Information
Patient Name
First Name
Last Name
Date of Birth
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
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Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Patient Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Patient Email
Patient Phone Number
Race
White
Black
Asian
Native American
Pacific Islander
Other
Other:
Other Value
Ethnicity
Hispanic
Non-Hispanic
Gender
Male
Female
Transgender, Male-Female
Transgender, Female-Male
Social Security Number
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Phone
Disease
Disease or Condition Name
Admission Date
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
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31
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Onset Date
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
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31
Year
2019
2020
2021
2022
2023
2024
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2027
2028
2029
Diagnosis Date
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
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31
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Discharge Date
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
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22
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27
28
29
30
31
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Symptoms
Was laboratory testing ordered?
Yes
No
If yes, attach the results:
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What the patient treated?
Yes
No
If yes, provide treatment details:
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Description of other illnesses/treatments
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