Infectious Disease Intake Form

The Infectious Disease Intake Form is purpose-built for infectious disease (ID) consultations, capturing the detailed exposure history, microbiologic data, and antimicrobial treatment records that ID specialists require for diagnostic reasoning and therapeutic planning. This template collects patient demographics alongside a thorough infection assessment including presenting symptoms with timeline, fever pattern characterization (continuous, intermittent, relapsing), prior culture and sensitivity results, imaging findings, and current antimicrobial regimens with duration, dose, and route of administration. The exposure history section systematically screens for travel to endemic regions, animal contacts, tick or mosquito exposures, occupational hazards (healthcare workers, agricultural workers), sexual history, injection drug use, incarceration history, and household or institutional contacts with known infections.

Designed for general infectious disease, HIV medicine, transplant infectious disease, and travel/tropical medicine practices, this form includes sections for immunization history (including COVID-19, influenza, pneumococcal, hepatitis A/B, MMR, Tdap, and travel-specific vaccines such as yellow fever, typhoid, and Japanese encephalitis), immune status evaluation (HIV status, CD4 count and viral load if applicable, immunosuppressive medications, history of splenectomy, solid organ or stem cell transplant, primary immunodeficiency), and prior infectious disease diagnoses including tuberculosis screening (TST, IGRA), latent TB treatment history, and healthcare-associated infection history (MRSA, VRE, C. difficile colonization or infection).

All fields are HIPAA-compliant and optimized for the ID consultation workflow. The multi-page format allows referring physicians and patients to document the clinical timeline comprehensively, including cultures obtained, empiric therapy administered, and response to treatment before the ID consultation. This structured pre-visit data collection enables the ID specialist to review the case efficiently, identify gaps in the diagnostic workup, and prepare targeted antimicrobial stewardship recommendations before the face-to-face encounter.